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RK301  M44  Oral  pathology  and^ 


BAJHOLOGY 


AND 


APEUTIGS 


Columbia  Winibtxaitv 
in  tf)t  Citj)  of  j^eto  Hork 

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A  systematic  presentation  of  the  suljject  from   the  standpoint    of    modern    therapeutics. 


WITH  11(1  ILLUSTRATIONS 


By 

ELGIN  ^IaWHINNEY,  D.D.S. 

Chicago. 

Professor  of  Special  Pathology,  Materia  Medica  and  Therapeutics,  Northwestern  University  Dental 

School;   Member  International   Dental  Federation,    National  Dental  Association, 

Chicago    Dental     Society,     Odontographic    Society   of  Chicago;   Secretary 

Illinois    State    Dental    Society,    etc.,    etc. 


THE  CONSOLIDATED  DENTAL  MFG.  CO. 
New  York,  N.  Y.,  U.  S.  A. 

CLAUDIUS  ASH  &  SONS   (Limited), 
London,  Eng. 

1905. 


Copyright,    1905,    by    Elgin    MaWhinney,    D.D.S. 
Entered  at  Stationers'   Hall,    London.  Eng. 


CHARLES  P.  PRUYN,  M.D.,  D.D.S, 

who   for  over  fifteen  years   has  been  my  friend  and    councillor 
in  all  the  affairs  of  life 

THIS  BOOK  IS  RESPECTFULLY  DEDICATED  BY 
THE  AUTHOR. 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/oralpathologytheOOmawh 


Preface, 


In  nearly  all  branches  of  dental  science  progress  has  been  rapid,  and 
especially  in  the  departments  of  surgery,  operative  procedures  and  pros- 
thodontia,  but  in  the  field  of  therapeutics  empirical  methods  of  treatment 
still  abide. 

This  volume  is  presented  with  the  hope  that  it  may  furnish  at  least 
a  rational  scientific  basis  for  the  management  of  many  oral  diseases  the 
treatment  of  which  constitutes  a  large  part  of  our  professional  service. 
The  recognition  and  prevention  of  disease  and  its  consequent  misery 
should  be  the  highest  aim  of  all  who  follow  the  healing  art  as  a  profession. 

It  has  been  the  aim  of  the  author  not  to  burden  the  volume  with  need- 
less pathological  or  histological  detail,  but  rather  to  present  such  phases 
of  these  subjects  as  will  furnish  a  scientific  basis  for  practical  therapeu- 
tics. Treatment  of  disease  without  knowledge  of  its  pathology  has  and 
always  will  be  a  decided  failure. 

Although  the  preparation  of  this  work  has  been  an  arduous  task 
coming  into  a  busy  professional  life,  still  it  has  been  a  pleasure,  for  the 
hope  of  being  helpful  to  the  toilers  of  the  profession,  as  well  as  to  those 
who  are  preparing  for  their  life's  work,  has  been  the  dominating  spirit  in 
which  the  work  has  been  done. 

The  author  wishes  to  disclaim  originality  for  much  of  the  subject 
matter  here  presented ;  for  the  most  part  it  has  been  gained  from  recog- 
nized authorities,  as  well  as  from  clinical  observations  in  the  college 
infirmary  and  private  practice  extending  over  a  period  of  nearly  twenty 
years,  supplemented  by  such  scientific  investigation  as  a  teacher  in  one 
of  our  large  schools  and  a  full  private  practice  would  permit. 

The  author  wishes  to  render  grateful  acknowledgment  to  Dr.  E.  S. 
Willard  for  personal  encouragcrhent  and  assistance  in  the  work,  and  to 
Dr.  G.  V.  Black,  Dr.  F.  B.  Noyes,  Dr.  Martin  H.  Fisher,  Dr.  G.  W. 
Cook,  Dr.  W.  D.  :Miller,  Prof.  Goadby,  Prof.  Hopewell  Smith,  Dr.  Osier, 
Dr.  Jas.  Nevins  Hyde,  Dr.  E.  S.  Talbot,  Dr.  John  S.  Marshall,  Dr.  J. 
Leon  Williams,  Dr.  Hugh  Blake  Baldwin,  Dr.  E.  C.  Kirk,  Dr.  Sudduth 
and  Dr.  Burchard,  whose  published  writings  have  been  drawm  on  for 
much  subject  matter  as  well  as  illustrations. 


Oral  Patbology  and  Cberapeutics. 

CHAPTER  I. 

Dental  paries* 

Introductory.      History.      Recent    Theories.      Etiology.       Bacteriology    of    Dental 
Caries.      Therapeutics.      Curative    Methods. 


Tntroductory. 

There  is  no  subject  in  the  entire  range  of  dental  science  that  is  so 
important  to  the  dentist  as  that  of  caries.  The  treatment  of  its  ravages 
constitutes  the  greater  part  of  his  professional  labors.  The  subject  will  be 
presented  in  this  chapter  from  a  therapeutic  rather  than  an  operative 
standpoint,  although  the  cure  of  its  ravages  most  frequently  requires 
operative  procedures. 

Tooth  decay  has  been  prevalent  in  all  ages  and  among  all  races  of 
people,  but  it  is  only  in  recent  years  that  its  nature  has  been  understood. 

Caries  of  the  teeth  is  a  pathological  process  differing  from  that  found 

in  the  tissues  in  that  it  is  not  associated  with,  or  a  result  of  preceding 

inflammation ;  dental  caries  consists  in  a  chemical  dissolution  of  the  tooth 

substance. 

history. 

In  the  literature,  the  names  of  Boudett  and  Jourdain  seem  to  be. 
associated  with  the  first  scientific  movement  about  1776,  which  afterwards- 
led  to  the  theory  of  decay  as  a  result  of  inflammation.  A  little  later  John 
Hunter  disputed  this  theory,  but  advanced  no  new  one. 

About  the  year  1806  Fox  offered  a  further  explanation  ;  he  held. 
decay  was  due  to  inflammation  of  the  lining  membrane  of  the  pulp  cham- 
ber. In  1829  Bell  and  Fitch  held  that  decay  was  due  to  inflammation  of 
the  dentine  immediately  underneath  the  enamel.  Koecker  held  that  not 
only  was  the  process  inflammation  of  the  dentine,  but  that  a  second  ele- 
ment entered  and  dissolved  the  dead  portion  by  means  of  chemical  decom- 
position. 

In  1835  Robertson  held  that  decay  was  due  to  chemical  decomposi- 
tion and  that  inflammation  had  nothing  to  do  with  the  process. 

Tomes  held  to  this  idea  and  added  that  there  was  some  disturbance 
of  the  dentine,  and  that  the  natural  resistance  of  dentine  to  decay  differed 
according  to  its  vitality. 

Here  the  matter  rested  for  many  years.  Dr.  Watt  adding  that  this- 
chemical  decomposition  was  due  to  mineral  acids  developed  in  the 
mucous  of  the  mouth.  A  little  later  Magitot  held  that  decay  was  due  tO' 
chemical  alteration  in  the  enamel  and  dentine  brought  about  through  acids 
developed  in  the  saliva  or  through  agents  introduced  into  the  mouth,  and 


•  7 

later  that  putrid   decomposition  of   animal   and   vegetable  substances   is 
responsible  for  acids  found  in  the  saliva. 

A  little  later,  about  1867,  he  brought  forward  the  theory  of  micro- 
organic  fermentation  as  a  cause  for  the  appearance  of  acids  in  the  saliva, 
and  that  these  acids  so  formed  were  the  direct  cause  of  tooth  decay. 

Recent  Cbecrlcs. 

Here  the  matter  rested  until  Miller  began  his  remarkable  series  of 
experim.ents,  the  results  of  which  were  published  in  1884  and  1885.  Pro- 
fessor Miller  clearly  demonstrated  that  caries  of  the  teeth  is  brought 
about  by  an  acid,  probably  lactic  acid,  produced  by  the  growth  of  micro- 
organism in  the  mouth.  While  Dr.  Miller  was  experimenting  and  study- 
ing in  Germany  Dr.  Black  was  at  work  along  the  same  lines  in  America, 
and  brought  out  the  additional  fact  that  decay  is  not  only  the  results  of 
acids  produced  by  micro-organic  fermentation,  but  in  order  to  cause  decay^ 
those  acids  must  be  produced  at  the  exact  point  where  decay  is  to  begin. 

The  profession  rather  reluctantly  accepted  this  theory,  and  much 
controversy  has  taken  place  in  relation  to  the  manner  in  which  these 
organisms  work.  Many  have  thought  that  some  teeth  were  more  prone  to 
caries  than  others  because  of  the  inherent  nature  of  the  tooth ;  that  some 
were  harder  than  others,  richer  in  lime  salts,  and  that  some  teeth  after 
calcification  undergo  a  degenerative  change,  especially  in  particular  spots^ 
which  render  them  more  liable  to  caries. 

All  of  these  notions  were  dashed  to  pieces  when,  as  a  result  of  experi- 
ments accurately  made.  Dr.  Black  in  1893  announced  to  the  profession 
that  teeth  do  not  materially  differ  in  this  regard,  and  that  our  term  hard 
and  soft  teeth  is  a  misnomer  as  far  as  liability  to  caries  is  concerned,  and 
that  "imperfections  of  teeth,  such  as  pits,  fissures,  rough  or  uneven  sur- 
faces, bad  forms  of  interproximate  contact  points,  are  causes  of  caries  only 
in  the  sense  of  giving  opportunity  for  the  action  of  the  causes  that  induce 
caries." — Black. 

The  carious  process  is  slightly  different  in  dentine  and  cementum 
from  that  of  enamel.  On  enamel  the  organism  has  to  do  its  work  under 
the  influences  of  a  changing  saliva,  and  in  the  presence  of  different  kinds 
of  food,  and  is  subject  to  dislodgment  by  the  excursion  of  foods  in  masti- 
cating, while  in  the  dentine  the  organisms  have  a  cavity  which  protects, 
them  from  most  of  these  influences. 

Enamel  is  harder,  has  less  animal  matter,  and  therefore  is  more  resist- 
ant in  a  certain  sense  than  dentine.  The  way  in  which  decay  of  enamel 
occurs  is  by  the  attachment  of  micro-organisms  to  its  surface,  and  by  their 
action  a  dissolution  of  the  cementing  substance  which  holds  the  enamel 
rods  in  place  is  the  first  step. 


Fig.  1. 

Bacilli  and  micrococci  in  dental  tubules.      C,  micrococci;   T,  bacilli.     (Hopewell   Smith.) 

With  dentine  a  somewhat  different  process  occurs.  As  soon  as 
enamel  is  destroyed  the  lime  salts  around  the  tubules  is  dissolved  and 
soon  the  organisms  penetrate  the  dentine  tubules,  Fig.  i,  and  then  spread 
laterally,  hence  it  is  that  decay  passes  into  the  tooth  in  a  somewhat  conical 
shape. 

Beyond  the  field  occupied  by  organisms  the  lime  salts  are  in  a  state 
of  decomposition  for  a  considerable  distance,  which  is  preparing  the  way 
for  further  ingress  of  the  organisms.  As  the  lime  salts  are  dissolved  there 
is  left  the  animal  matrix  which  furnished  food  for  these  organisms. 

The  profession  has  been  slow  to  take  up  these  theories  of  Miller  and 
Black;  many  objections  have  been  offered,  chief  of  which  centered  in  the 
thovight  expressed  in  the  question,  how  is  it  possible  for  micro-organisms 
to  temain  in  contact  with  luibroken  enamel  long  enough  to  accomplish 
its  dissolution?  This  question  was  finally  answered  by  Dr.  J.  Leon  Wil- 
liams, of  London,  England,  in  1897.  ^^  demonstrated  that  the  micro- 
organisms that  cause  tooth  decay  are  gelatine  producing  organisms. 
These  organisms  collect  in  protected  spots  about  the  teeth  and  form  a 
gelatinous  film  which  is  very  adherent  to  the  enamel,  and  under  this  pro- 
tection they  do  their  work.  Dr.  Williams  succeeded  in  grinding  speci- 
mens thin  enough  without  disturbing  the  gelatinous  plaque  over  the 
decaying  enamel  to  show  the  carious  process,  Fig.  2.  These  gelatinous 
plaques  seem  to  be  rio  bar  to  the  passage  of  food  material  for  the 
organism. 


y 


Fig.  2. 
From  a  section  of  human  enamel  in  early  stages  of  decay.     A,  micro-organisms  deeply  stained; 
b    evidences  of  recent  vigorous  action  of  acids;   c,  temporary  arrest  of  the  organisms.     (Williams.) 


etiology. 


Trom  a  Cberapcutic  Standpoint 

The  present  understanding  of  the  causes  that  have  to  do  with  tooth 
decay  are  divided  into  two  classes,  predisposing  and  exciting. 

By  predisposing  causes  is  meant  that  condition  of  the  general  system 
whereby  the  secretions  of  the  mouth  favor  a  certain  kind  of  micro-organic 
growth  and  development.  Just  what  these  conditions  of  saliva  are  has  not 
been  made  out.  It  was  formerly  believed  that  acid  conditions  favor  the 
carious  process,  but  this  has  been  proven  erroneous.  Certain  it  is  that 
the  presence  of  carbohydrates  in  the  saliva  favor  the  process,  for  they 
act  as  food  material  for  the  organisms. 


lO 

The  second  predisposing  cause  lies  in  tooth  imperfections  which 
make  favorable  places  for  these  organisms  to  take  hold  and  develop. 

The  exciting  cause  is  acid  produced  at  the  immediate  point  of  decay 
by  the  action  of  micro-organisms. 

Bsctcriology  of  Dental  Caries. 

Tooth  decay  is  essentially  a  bacteriological  problem.  Without  bac- 
teria there  would  be  no  tooth  decay.  They  are  found  everywhere,  and 
especially  in  the  human  mouth ;  here  certain  forms  are  constantly  found. 

It  seems  that  both  coccus  and  bacillus  forms  have  to  do  with  caries, 
although  Miller  was  formerly  of  the  opinion  that  only  the  bacillus  form 
were  directly  concerned.  He  isolated  four  varieties  of  bacillus,  and 
Goadly  classifies  three  forms  of  cocci  in  addition.  Black  is  of  the  opinion 
that  both  varieties  have  to  do  with  caries,  and  certainly  they  are  both 
frequently  found  in  the  dentinal  tubules,  as  Fig.  i  illustrates. 

Cberapeutics. 

What  has  been  said  up  to  this  point  is  a  brief  resume  of  the  carious 
process  given  as  a  basis  for  the  practical  therapeutics  of  the  subject. 

The  practical  therapeutics  of  this  subject  can  most  easily  be  presented 
under  two  heads. 

First,  Prophylaxis,  which  relates  to  the  means  of  preventing  or 
limiting  tooth  decay.  Second,  Curative  methods,  which  relate  to  the 
arresting  of  its  ravages  in  a  given  tooth  or  several  teeth  when  the  carious 
process  has  once  begun. 

The  subject  of  prophylaxis  is  one  of  great  interest,  and  although 
caries  has  been  known  for  many  centuries,  still  very  little  has  been  accom- 
plished in  the  way  of  prevention.  It  is  in  this  direction  that  scientific 
work  is  needed. 

Since  bacteria  everywhere  abound,  it  is  not  possible  for  us  to  prevent 
them  gaining  access  to  the  oral  cavity,  but  we  are  able  to  hold  in  check 
their  ravages  by  three  methods. 

First  and  most  important  relates  to  the  limiting  of  their  food  material, 
which  can  only  be  done  by  limiting  the  amount  of  carbohydrates  allowed 
to  remain  in  the  oral  cavity.  Second  relates  to  the  cultivation  of 
habits  of  cleanliness  about  the  oral  cavity.  Third  relates  to  the  use  of 
antiseptics  in  the  oral  cavity  that  will  in  a  measure  at  least  control  bac- 
terial activity. 

It  should  be  stated  that  while  carbohydrates  are  essential  to  proper 
nutrition,  the  tendency  to  consume  far  in  excess  of  the  needs  of  the  system 
is  very  great,  especially  among  children.  After  all,  the  important  point  of 
the  matter  is  not  to  allow  these  things  to  remain  in  the  mouth  long  enough 
to  undergo  fermentation. 


II 

The  second  method. 

Many  a  person  is  unclean  about  his  mouth  because  he  does  not 
know  how  to  properly  care  for  it  and  others  fall  into  careless  habits.  If 
individuals  could  be  taught  to  habitually  cleanse  every  surface  of  every 
tooth  twice  daily  there  would  be  very  little  decay.  As  stated  before,  these 
gelatinous  plaques  cling  in  out-of-the-way  places,  and  unless  an  efifort 
is  made  to  cleanse  these  spots  decay  will  result. 

The  eating  of  coarse  foods  has  a  tendency  to  cleanse  the  teeth  by  its 
excursion  over  their  surfaces  in  mastication,  and  from  this  standpoint  is 
valuable.  Some  think  too  much  brushing  injures  the  teeth,  but  I  have 
never  seen  such  a  case.  For  prevention  of  decay,  on  retiring  is  the 
important  time  to  brush. 

This  subject  will  be  treated  further  in  the  chapter  on  Cleaning  Teeth. 

The  third  method,  regarding  the  use  of  antiseptic  mouthwashes,  it 
should  be  stated  that  no  known  remedy  can  be  used  strong  enough  to 
insure  thorough  antisepsis.  Such  a  thing  as  asepsis  of  the  oral  cavity 
cannot  be  hoped  for.  There  are  remedies  that  would  render  conditions 
decidedly  antiseptic,  but  they  are  so  irritating  to  soft  tissue  that  they  can 
only  be  employed  in  attenuated  solutions. 

Most  mouthwashes  in  the  market  are  antiseptic  in  their  tendency, 
although  the  most  of  them  are  more  adapted  to  furnishing  a  pleasant  taste 
than  to  rendering  conditions  antiseptic.  Conditions  of  the  mouths  differ, 
requiring  a  little  different  wash  for  each  case. 

The  agents  that  will  furnish  a  basis  from  which  to  combine  a  mouth- 
wash adapted  to  individual  mouth  conditions  are  benzoic  acid,  borax,, 
carbolic  acid,  boric  acid,  oil  cassia,  trikresol,  Black- 1-2-3,  bichlorid  of 
mercury,  hydrogen  dioxid,  permanganate,  wintergreen  and  other  essen- 
tial oils  as  flavors. 

In  the  use  of  an  antiseptic  mouthwash  the  patient  should  not  only 
rinse  the  mouth  but  should  hold  a  mouth  full  of  the  solution  for  several 
minutes. 

€uratiDe  methods. 

The  curative  methods  are  three.  First,  The  removal  of  all  disinte- 
grated tooth  substance  and  polishing  the  surface.  Second,  The  removal 
of  decay  and  filling  the  cavity.  Third,  The  use  of  medicinal  agents  that 
arrest  the  progress  of  decay. 

The  first  method  is  only  adapted  to  those  cases  where  only  a  slight 
amount  of  enamel  is  disintegrated,  and  which  can  be  removed  without 
exposing  the  dentine  or  impairing  the  service  form  of  the  tooth  or  its 
approximate  contact.  In  these  cases  not  only  should  the  softened  enamel 
be  removed,  but  that  surface  should  be  made  smooth  and  highly  polished. 


12 

Second,  The  curative  effects  of  fillings  depend  on  three  things,  that 
the  area  of  liability  of  that  cavity  has  been  included  in  the  prepared 
cavity,  and  that  a  properly  shaped  tight  filling  is  made  and  that  no  dentine 
has  been  left  exposed. 

The  third  method  relates  to  the  use  of  such  agents  as  nitrate  of  silver 
in  shallow,  slow  forming  cavities  in  deciduous  teeth,  which  will  often 
arrest  decay  until  time  for  them  to  be  shed.  This  method  is  also  recom- 
mended in  those  cases  where  slight  decay  occurs  along  the  gingival  line 
of  molars  and  bicuspids.  Not  only  will  it  relieve  the  sensitiveness  which  is 
usually  found  at  those  points  but  will  often  arrest  further  decay.  Other 
agents  have  been  suggested,  for  example,  formalin,  chloride  of  zinc, 
trichloracetic  acid. 

Recently  McKesson  &  Robbins  have  suggested  a  tooth  powder  of 
calcium  carbonate  which  will  generate  hydrogen  dioxide  when  in  contact 
with  the  lactic  acid  of  decay,  which  they  claim  will  effectually  arrest 
decay. 


CHAPTER  II. 


Cbe  Dentdl  Pulp. 

The  Functions  of  the  Pulp.     Sensitive  Dantine.    Other  Cells.    Blood  Vessels.    Nerve 

Supply. 

Before  entering  into  a  study  of  pulp  diseases  it  seems  wise  that  we 
hastily  reveiw  the  histology  of  the  tissues  involved. 

Dental  pulp  is  the  name  given  to  the  soft  tissue  occupying  the  central 
cavity  of  the  dentine.  It  is  made  up  of  embryonal  connective  tissue,  and 
many  blood  vessels  and  nerves,  but  no  lymphatics.  There  are  four  dis- 
tinct kinds  of  cells,  easily  recognized  the  odontoblasts.  Fig.  3,  round, 
spindle  shaped,  and  stellate  cells.     The  odontoblasts  form  a  continuous. 


Fig.  3. 
Odontoblasts    clinging    to    a    fragment     of      dentine,      showing     their    form.     (Black.) 

layer  over  the  surface  of  the  pulp,  sometimes  referred  to  as  the  membrane 
eboris.  (See  Fig.  4).  This  so-called  membrane  is  composed  of  columnar 
cells  lying  close  to  each  other,  and  sometimes  present  the  appearance  of 
being  crowded  out  of  shape.     Each  cell  has  four  projections  or  processes. 

1.  The  dentinal  fibrils  or  fibers  of  Tomes. 

2.  Tw'o  lateral  fibrils  extending  from  the  sides  of  each  cell  and 
uniting  with  adjoining  cell  to  make  a  complete  layer. 

3.  A  process  passing  into  the  pulp  tissue. 

The  fibers  of  Tomes  are  small  projections  which  extend  from  the 
cell  proper  out  through  the  dentinal  tubules  to  the  enamel  and  cementum^ 
(See  Figs.  5  and  5a  and  6). 


'4 


Fig.  4. 
Longitudinal  section  pulp.     O,   odontoblasts;   D,  dentine;   P,  pulp.    (Noyes.) 


r 


.l-!g.  5a. 
Section  of   dentine   from  the   root,    cut  in  length  of  tubyles.      (Noyes.) 


i'ig.  .1 
Section   of   dentine  in   crown    cut  in   length   of  tubules.     (Xoyes.) 


i6 


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1=/  ■       -  v^- 
^^  v/    ^'    '■' 

L.,  .«#,., 

■•4* 

....r^..  .-.!# 

.Xji    -: 

.^_>*J 

Fig.  6. 

Section  of  dentine  at  right  angles  to  tubules.      (Noyes.)    . 

Cbe  functions  of  tbe  Pulp, 

The  dental  pulp  performs  two  functions,  viz.,  a  vital  and  a  sensorv 
function.  The  vital  function  is  the  building  of  dentine,  which  is  done 
through  the  odontoblastic  layer.  This  function  is  most  active  while  the 
papilla  Is  large  and  dentine  is  forming,  but  after  the  tooth  is  once  thor- 
oughly formed  this  function  seems  to  lie  dormant  unless  some  irritation 
excites  the  trophic  centers,  which  may  result  in  the  formation  of  secondary 
dentine.  The  sensory  function  resembles  that  of  the  internal  organs  of 
the  body — sensation  of  pains  when  irritated  in  any  manner,  but  has  not 
the  sense  of  touch.  This  explains  the  difficulty  Ave  experience  in  locating 
the  source  of  pain  when  it  comes  from  a  vital  pulp.  There  is  one  other 
important  point  regarding  the  normal  pulp  which  has  a  very  direct  bear- 
ing upon  the  pathology,  and  that  is  this — the  pulp  tissue  completely  fills 
the  chamber  and  root  canals. 

Sensitive  Dentine. 

Normal  dentine  is  not  very  sensitive,  and  the  same  is  true  of  the 
pulp.  The  most  generally  accepted  explanation  regarding  sensitiveness 
of  the  dentine  is  about  as  follows :  The  fibrils  of  Tomes,  as  we  have 
before  stated,  are  prolongations  of  the  substance  of  the  odontoblasts  ; 
they  are  a  portion  of  the  odontoblasts  extending  through  the  dentine  to 
the  dento-enamel  junctions.  These  cells  lie  in  direct  physiological  rela- 
tion with  the  nerves  of  the  pulp.     (See  Figs.  3  and  4.) 


17 

Oih«r  eells. 

There  does  not  seem  to  be  any  regular  arrangement  for  the  other  cehs 
of  the  pulp.  For  the  most  part  they  may  be  said  to  be  sparsely  scattered 
throughout  the  tissue,  assuming  some  regularity  along  the  blood  vessels. 
These  cells  are  held  in  a  gelatinous-like  matrix  with  few  fibers. 

Blood  Uessels. 

The  blood  supply  of  the  pulp  is  abundant ;  a  number  of  arteries  enter 
through  the  apical  foramen,  and  extend  occlusally  through  the  central 
portion  of  the  tissue,  giving  off  many  small  capillaries    (Fig.  7).     The 


Fig.  7. 

Blood  supply   in   point   of   pulp. 


(Black.) 


blood  is  collected  into  the  veins  and  returns  apically  through  the  central 
portion  of  the  pulp  tissue,  passing  out  through  the  apical  openings.  The 
blood  supply  does  not  always  all  come  from  the  inferior  and  superior 
dental  arteries,  but  sometimes  a  portion  of  it  comes  from  the  alveolar  cir- 
culation, and  occasionally  there  are  lateral  openings  through  the  sides 
of  the  roots.  An  interesting  specimen  is  now  in  the  school  museum.  The 
thinness  of  the  arterial  walls  is  a  peculiarity  which  we  need  to  remember. 

nerve  Supply. 

Several  large  bundles  of  nerve  fibers  enter  the  pulp  along  with  the 
blood  supply  and  occlusally  through  the  central  portion,  giving  off  many 
branches,  which  penetrate  the  entire  tissue,  even  passing  between  the  cells 


of  the  odontoblastic  layer.     As  yet  no  fibers  have  been  seen  to  follow  into 
ihe  dentinal  tubules. 

Whenever  these  fibrils  are  irritated  the  sensation  is  carried  directly 
to  the  sensorium  through  the  central  ganglia.  The  area  of  dentine  that  is 
most  sensitive  is  at  the  termination  of  these  fibrils — and  in  this  particular 
they  resemble  other  nerve  endings.  It  is  the  finger  tips  that  are  most 
sensitive,  not  the  deeper  parts.  This  leads  up  to  the  consideration  of 
hypersensitive  dentine. 


CHAPTER  III. 

1)ypcr$en$itive  Dentine. 

The  Management  of  Sensitive  Cases.      Systemic  Medication.    Management  of  Sen- 
sitive Dentine.     Obtundants.     Thermal   Sensitiveness. 


Che  IDanagtmcnt  of  Sensitive  €4$e$. 

Hypersensitive  dentine  is  a  term  used  to  designate  dentine  which  is 
unusually  sensitive  to  filling  operations;  it  is  a  subject  that  has  attracted 
the  best  thought  of  the  profession  ever  since  filling  operations  began. 

The  proper  preparation  of  cavities  is  often  a  very  painful  process; 
patients  differ  widely  in  this  regard.  A  cavity  that  is  unusually  painful 
for  one  may  scarcely  be  at  all  sensitive  for  another,  although  the  cavity 
may  be  very  similar  and  the  process  of  preparation  be  identical.  Why  is 
this  ?  Why  do  patients  suffer  so  differently  from  similar  operations  ?  The 
reason  may  be  one  or  all  of  three.  First,  the  condition  of  the  fibrils  may 
be  large  and  active  to  slight  irritation,  i.  e.,  they  may  respond  to  the 
■slightest  irritation.  Second,  the  nervous  sensibilities  may  be  more  acute. 
A  slight  irritation  may  be  magnified  in  its  transmission  to  the  brain.  It 
may  be  true  that  this  nerve  of  transmission  is  perverted  in  itself,  magni- 
fying the  actual  irritation  before  it  gets  to  the  center,  and  so  the  patient 
•suffers  increased  pain  from  that  cause.  And  the  third,  the  fear  or  dread 
of  the  operation,  may  have  induced  an  oversensibility  in  the  pain  centers 
of  the  brain,  responding  to  the  slightest  irritation,  etc.  In  preparing 
■cavities  in  teeth  containing  living  pulps  we  are  usually  causing  pain,  be- 
-cause  we  are  actually  working  on  live  tissue  capable  of  responding  to  the 
slightest  irritation.  The  manner  in  which  these  dentinal  fibrils  respond  to 
irritation  has  already  been  explained.  Another  element  that  enters  into 
the  cause  of  pain  in  these  cases  is  the  peculiar  noise  made  by  the  instru- 
ments used  in  the  work ;  particularly  is  this  true  of  burs  and  stones  in  the 
engine.  Patients  frequently  present  themselves  in  a  highly  nervous,  ex- 
cited condition,  due  to  meditating  upon  the  fact  that  they  have  som-cthing 
to  be  done  which  they  think  will  cause  the  ma  degree  of  suffering  beyond 
their  power  to  endure.  I  might  say  that  this  is  quite  the  usual  attitude 
of  mind  that  the  patients  present  if  they  are  coming  to  you  for  the 
first  time.  Not  infrequently  they  faint  upon  sitting  in  the  dental  chair 
before  you  have  done  anything  at  all  for  them.  This  is  an  experience 
which  I  have  had  a  number  of  times,  and  others,  too,  have  had  the  same 
•experience. 


20 

Our  success  in  practice  building  will  depend  on  our  ability  to  decide 
what  to  do  for  these  patients.  If  for  a  few  minutes  I  seem  to  digress  and 
preach  a  sort  of  sermon  I  hope  you  will  excuse  it.  There  are  some 
things  that  I  want  to  impress  upon  your  minds  now ;  they  have  been  so 
profitable  to  me  and  so  profitable  to  hundreds  of  others,  and  I  think  this 
is  a  good  way  to  do  it.  The  first  thing,  then,  that  we  must  do  for  these 
patients,  presenting  themselves  in  the  condition  that  I  have  indicated,  is 
that  we  must  get  their  confidence.  How  is  this  done?  I  can't  tell  you. 
Each  case  perhaps  itself  inspires  the  operator  with  the  knowledge  of  what 
to  do;  but  I  want  to  indicate  to  you  along  what  line  it  comes.  I  am  sure 
all  of  you  have  had  cases  that  to  work  for  was  irksome,  not  because  of  the 
work  itself,  but  because  of  the  condition  of  the  patient,  or  the  attitude 
of  the  mind  of  the  patient  towards  you.  They  have  a  sort  of  a  notion  that 
you  are  not  going  to  do  the  work  well,  perhaps,  or  that  you  will  hurt  them 
needlessly,  and  you  can  never  get  them  to  have  confidence  in  what  you 
are  going  to  do.  When  you  get  into  practice  here  are  some  of  the  things 
you  must  consider.  First,  the  personnel  of  the  dentist.  You  must  have 
a  professional  air  about  you.  You  want  to  recognize  the  fact  that  our 
calling  is  something  more  than  trade ;  that  it  is  a  profession ;  there  is  a 
dignity  about  it,  a  professional  air.  Kind  in  manner  and  speech,  and,  as 
someone  has  said :  "Keep  your  voice  low."  There  is  a  whole  lot  in  that. 
The  dentist,  of  course,  must  be  clean,  quiet,  cool-headed  and  in  perfect 
poise.  ■  If  you  are  nervous  yourself  about  what  you  are  going  to  do;  if 
your  mind  is  all  uneasy  and  your  hand  is  shaky  and  you  are  in  dread  of 
what  you  are  going  to  undertake  yourself,  you  can  be  sure  that  the 
patient  will  catch  every  bit  of  that  and  magnify  it  in  himself  or  herself. 
I  would  like  to  cite  you  a  little  incident  which  came  to  my  notice  some 
years  ago.  One  of  my  confreres  in  practice  here  in  the  city,  a  most  thor- 
ough dentist  and  an  excellent  gentleman,  came  to  me  one  day  and  said: 
"Doctor,  I  don't  know  what  I  am  going  to  do;  every  patient  that  has 
come  to  me  this  week  has  fainted."  I  said:  "How  many  hours  a  day  are 
you  working?"  "About  twelve."  I  said:  "You  look  as  though  you  were. 
How  long  since  you  had  a  vacation  ?"  "I  didn't  get  my  vacation  this  year  ; 
I  was  so  busy  and  had  so  much  to  do  that  I  couldn't  get  away."  "You 
had  better  take  your  vacation  now ;  now  is  the  time.  Your  patients  are 
fainting  because  you  impart  this  dread  and  fear  to  them  yourself.  You 
are  all  nerves ;  you  are  all  unstrung ;  you  can't  do  anything  the  way  you 
want  it  done ;  you  can't  find  your  instruments,  and  when  you  do  you  drop 
them  on  the  floor.  You  had  better  take  a  vacation."  He  took  my  advice, 
and  when  he  came  hgme  from  his  vacation  he  didn't  have  any  more  people 
fainting  in  his  chair.  Then,  you  must  give  the  patient  your  undivided 
attention.     Don't  hurry,  take  your  time,  and  give  the  patient  all  your 


21 

attention.  Then,  of  course,  the  dentist  himself  must  be  clean  as  to  his 
morals.  What  we  are  shows  in  our  faces  and  our  demeanor  in  every  way ; 
we  can't  hide  it ;  we  can't  debauch  and  conceal  it.  Then  the  next  thing 
is  the  office  itself.  The  office  must  be  clean  and  tidy ;  there  must  be 
evidences  that  the  patient's  comfort  is  considered,  and  above  all  it  must 
have  a  business-like  air,  i.  e.,  it  must  appear  to  the  patients  when  they 
come  in  that  this  is  a  place  where  people  come  to  have  dental  work 
done.  It  is  not  a  place  to  play  in.  It  is  a  business  office  where  everything 
is  arranged  for  the  comfort  of  your  patients  and  to  execute  business.  You 
don't  know  what  an  impression  it  makes  upon  patients  for  the  first  time 
if  they  find  an  air  of  business  about  your  office  in  general.  I  once  went 
into  an  office  and  saw  in  the  reception  room  the  gentleman's  hunting  boots 
tliat  had  been  there  from  the  season  before,  and  a  lot  of  traps  pertaining 
to  his  hunting  outfit  laying  there,  covered  with  dirt  and  papers  and  cir- 
culars and  things  wdiich  will  accumulate  were  thrown  over  this,  and  on 
every  chair  you  could  write  your  name  in  the  dust.  I  went  into  his  pri- 
vate office,  and  what  did  I  see?  On  the  bracket  of  his  chair  lay  a  forcep 
with  an  old  tooth  in  it.  That  tooth,  I  am  sure,  had  been  extracted  the 
day  before,  at  least.  The  cuspidor  was  all  covered  with  dried  blood  and 
sputum.  I  said  to  him:  "How  is  business?"  He  said:  "Business  is 
bum."  That  gentleman  tried  to  practice  in  Chicago  for  upward  of  fif- 
teen years,  and  he  has  gone  to  a  little  town  of  one  thousand  inhabitants 
now.  Not  that  he  was  not  a  good  dentist,  for  he  was,  but  the  inattention 
to  all  these  details  disgusted  everybody.  Then,  have  an  absence  of  dis- 
agreeable odors  about  the  office.  How  often  you  have  patients  tell  you 
that  the  odor  about  a  dentist's  office  is  the  hardest  thing  for  them  to 
bear.  You  do  not  need  anything  of  the  kind ;  have  the  cuspidor  clean. 
And  do  not  have  any  instruments  in  sight ;  that  is  a  hobby  of  mine. 
When  I  first  began  practice  I  thought  a  pretty  good  stock  in  trade  would 
be  to  have  a  nice  array  of  nickel  plated  instruments  in  sight.  So  I 
started  out  with  that  idea,  and  patients  would  look  in  the  direction  of 
these  instruments,  especially  the  extracting  forceps,  and  wish  they 
hadn't  come.  I  never  have  any  instruments  in  sight  now ;  I  mean  by 
that,  when  the  patients  comes  into  my  operating  room  to  have  their  teeth 
examined  they  sit  in  the  chair,  and  there  is  not  an  instrument  in  sight. 
I  have  my  case  convenient  and  my  instruments  so  arranged  that  I  can 
put  my  hand  on  any  instrument  I  want  immediately.  Then  after  they  are 
used  the  young  lady  takes  them  and  sterilizes  and  sharpens  them,  and 
puts  them  back  where  they  were  before.  This  is  a  thing  that  I  have  no 
special  patent  on;  others  do  it  the  same  as  I  do.  Then  you  want  your 
instruments  clean.  •  Nothing  will  disgust  a  patient  so  quickly  as  for  you 
to  dismiss  one  patient  and  invite  another  one  in  with  the  dirty  instru- 


22 

ments  you  have  been  using  lying  on  your  bracket.  Perhaps  people  who* 
do  not  think  of  these  things  do  not  care,  but  the  class  of  patients  that 
you  want  do  care.  The  world  over  the  laity  understand  about  infection ; 
they  understand  about  the  danger  of  carrying  disease  from  one  to  an- 
other on  instruments,  and  you  will  fool  yourself  if  you  think  they  don't. 
I  have  had  any  number  of  patients  come  to  me  for  the  reason  that  their 
dentist  seemed  to  use  instruments  on  one  after  another  without  sterilizing. 
In  the  first  place  it  isn't  correct  practice ;  if  you  should  infect  a  patient 
in  that  way  you  would  be  liable  for  malpractice ;  and  in  the  second  place, 
it  is  absolutely  false  business  principles.  Then  attend  to  the  details  for 
the  patient's  comfort.  One  of  those  little  details  is  this,  and  will  serve  to 
make  clear  my  meaning :  patients  often  come  with  their  lips  chapped,  and 
you  should  have  a  little  cold  cream  or  something  of  the  kind,  that  you 
can  smear  on  the  lip  to  protect  it.  Let  the  patients  have  an  idea  that  you 
are  thinking  a  little  about  their  comfort.  Then  assure  your  patient  that 
your  aim  is  to  work  with  as  little  pain  as  possible,  and  do  operations  well, 
that  you  will  not  hurt  needlessly.  I  say  to  patients :  'T  will  tell  you  when 
I  am  going  to  hurt,  and  so  you  need  not  be  expecting  it  until  I  tell  you.'^ 
That  helps  a  whole  lot.  And  then  they  don't  worry  about  it.  And  get 
your  patients  calm  and  relaxed  before  you  attempt  to  do  anything.  Make 
Lhem  let  go  of  their  nervous  tension.  You  will  find  patients  when  they 
come  for  the  first  time  will  usually  grip  hold  of  the  arm  of  the  chair,  put 
their  feet  down  against  the  footrest  and  stififen  themselves  right  up — just 
the  opposite  to  what  you  want  them  to  do.  The  first  thing  to  do  is  to 
explain  to  them  the  philosophy  of  the  action  of  their  nervous  system 
regarding  pain,  which  can  be  done  in  half  a  dozen  sentences,  and  get 
patients  to  release  their  hold  on  the  chair,  drop  their  hands  at  their 
side  or  into  their  lap  and  relax  themselves  entirely ;  tell  them  to  take 
in  a  few  full  breaths,  quiet  and  restful ;  lower  your  voice  and  talk  to  them 
in  that  way,  and  tell  them  to  Just  forget  themselves  and  let  their  mind 
be  relaxed.  I  do  not  know  anything  about  hypnotism,  but  if  this  is 
hypnotism  that  is  the  thing  you  want  to  practice ;  it  will  bring  you  success, 
I  think  I  used  to  suffer  more  than  anybody  else  having  my  teeth  attended 
to;  dentists  always  do.  When  you  get  into  practice  and  have  25  or  30 
dentists  on  your  regular  list  you  will  find  that  they  always  think  they  are 
the  ones  who  suffer  the  most.  I  was  sure  I  did.  I  used  to  have  a  terrible 
time.  I  got  to  thinking  about  this  thing,  and  I  concluded  I  would  prac- 
tice on  myself  some  of  the  things  I  was  preaching.  I  go  to  my  dentist 
and  sit  down  in  the  chair,  and  in  a  few  minutes  I  get  myself  so  relaxed 
that  scarcely  any  operation  in  the  mouth  causes  me  any  pain  whatever. 
Not  that  I  am  not  just  as  sensitive,  but  because  I  am  able  to  relax  my 
entire  system  in  such  a  way  that  I  suffer  less  than  others  do.    That  is  the 


23 

kind  of  thing  I  want  you  to  get  in  the  habit  of  doing.  You  will  be  aston- 
ished to  find  how  it  will  aid  you.  Then  after  you  have  done  this  under- 
take something  easy  the  first  sitting  and  gradually  work  towards  the 
more  difficult  and  severe.  When  your  patient  trusts  you  implicitly  you 
have  won  a  lasting  friend  and  a  most  profitable  patient.  The  fact  of  the 
matter  is,  if  you  will  just  take  time  to  do  this  thing  the  first  time  the 
patient  comes,  you  will  have  no  trouble  in  keeping  that  patient  as  long  as 
you  are  in  practice.  They  will  come  to  you  under  all  circumstances.  It 
is  the  first  visit  that  bothers  all  of  us.  I  have  patients,  and  so  has  every 
practitioner,  the  first  time  they  came  to  me  was  almost  killing  on  myself 
to  do  anything  for  them.  Every  move  you  make  their  hands  will  go  up 
and  catch  your  hand.  "Oh,  dear,  I  really  don't  think  I  can  stand  this; 
you  will  have  to  let  me  rest  awhile,"  and  all  that  sort  of  thing,  and  you 
put  in  an  hour  or  two  in  doing  something  that  you  could  do  in  five 
minutes. 

But  when  they  get  confidence  in  what  you  are  going  to  do,  you  will 
not  have  any  trouble.  I  have  people  with  whom  I  have  had  just  such 
experience,  who  come  to  me  now  v/ithout  the  least  dread,  and  it  is  a 
positive  pleasure  to  work  for  them.  I  remember  one  case  in  particular 
about  eight  years  ago.  I  was  associated  in  my  office  at  that  time  with  a 
very  estimable  gentleman.  This  patient  made  so  much  fuss  that  it  dis- 
turbed his  patient  and  himself  and  everyone  in  the  office,  over  work  that 
was  not  painful  in  itself,  and  I  pretty  near  killed  myself  trying  to 
do  decent  work  for  her  the  first  few  visits. 

Finally  my  associate  came  to  me  and  said :  "There  is  no  use  talking, 
you  will  have  to  let  that  patient  go  or  she  will  drive  everybody  out  of  the 
office."  I  was  quite  inclined  to  adopt  his  notion  of  it;  but  I  finally  got 
through  with  that  series  of  operations,  and  I  have  had  no  trouble  with 
that  patient  since.  She  comes  to  me  regularly  and  has  sent  me  dozens  of 
others.  She  came  to  me  from  another  dentist  because  his  operations 
were  not  successful ;  she  was  losing  fillings  all  the  time.  Why  ?  Not  be- 
cause he  wasn't  a  good  dentist,  but  because  he  couldn't  get  that  woman 
into  condition  where  he  could  work  for  her.  If  you  cannot  get  a  patient's 
confidence  let  him  go.  You  can't  afford  to  do  otherwise.  Working  for 
people  who  are  set  against  everything  you  are  going  to  do  is  absolute 
folly,  because  you  are  killing  yourself,  you  are  killing  the  patient,  you 
are  doing  poor  work ;  you  can't  help  yourself,  and  it  will  add  nothing  to 
your  credit,  and  in  building  up  a  practice  you  do  not  care  so  much  for 
cases  that  just  happen  in  to  have  something  done.  What  you  want  are 
families  that  are  going  to  come  to  you  year  after  year,  that  are  going  to 
say  a  good  word  for  you  among  their  neighbors  and  friends,  and  because 
you  are  just  starting  in  practice  and  need  every  dollar  you  can  get  will 


24 

lead  you  to  undertake  things,  just  for  the  sake  of  that  income  which  you 
cannot  properly  do.  Such  a  procedure  is  absolutely  foolish  business 
policy.  If  you  dismiss  that  patient  with  a  distinct  understanding,  say 
to  him :  "You  have  no  confidence  in  what  I  am  trying  to  do  for  you ;  you 
have  set  yourself  against  what  I  am  trying  to  do,  and  under  those  condi- 
tions I  cannot  do  you  good  work ;  I  am  unwilling  to  do  what  I  know  to 
be  poor  work,  and  you  will  have  to  go  to  someone  else."  That  will  often 
bring  them  to  their  senses  and  they  will  appreciate  what  you  are  trying 
to  do.  Make  a  practice  of  studying  each  patient ;  no  two  are  exactly 
alike,  and  what  I  have  said  will  not  appl}'  to  each  case,  but  will  serve  to 
indicate  the  method  of  procedure.  In  managing  children  in  order  to 
have  them  bear  things  that  are  painful  requires  a  good  deal  of  tact.  And 
your  success  in  m.anaging  these  little  folks  has  much  to  do  with  building 
up  a  practice,  for  it  is  astonishing  how  rapidly  little  folks  grow  up  to 
be  big  folks. 

Systemic  medication. 

For  the  purpose  of  allaying  this  nervous  irritability  we  frequently 
need  to  call  to  our  aid  some  systemic  remedies.  Hypnotic  anodynes, 
agents  that  have  the  power  of  allaying  sensibilities  of  the  nerve  centers, 
or  the  peripheral  terminations,  are  those  of  most  value  to  us.  In  this 
class  belongs  opium  and  its  various  preparations  and  most  important  alka- 
loids, chloral,  trional,  sulphonal,  bromide  of  potassium.  Morphine  is  one 
of  the  alkaloids  of  opium,  and  the  one  mo^t  used.  For  purposes  of  alle- 
viating pain  it  is  without  a  rival.  It  is  given  in  doses  of  j4  grain  an  hour 
before  the  operation,  and  another  fifteen  minutes  before.  I  never  tell  my 
patients  what  they  are  taking  when  they  take  morphine,  because  so  many 
have  a  prejudice  against  it.  When  they  come  in  for  exam.ination  and 
you  recognize  that  you  are  going  to  have  trouble,  you  can  give  them 
one  of  these  little  tablets,  and  tell  them  to  take  it  an  hour  before  they 
come  the  next  tirne,  and  when  they  come  to  the  office  you  give  them 
another  one. 

Dover  powder  is  the  form  of  opium  frequently  given  for  allaying 
painful  conditions,  especially  about  the  peridental  membrane,  in  5  gr. 
doses.  .    " 

Codeine,  another  alkaloid,  is  frequently  used ;  it  is  much  less  powerful 
than  morphine. 

Chloral  is  often  of  value,  especially  for  the  purpose  of  allaying  ner- 
vousness where  there  is  little  pain  to  be  endured.  In  large  doses  chloral 
produces  sleep  quite  like  natural  sleep,  from  which  the  patient  can  readily 
be  aroused.  If  operations  are  painful  it  is  not  so  valuable  as  the  opium 
preparations,  but  I  have  had  very  excellent  results  in  doses  of  from  5  to 
20  grains  simply  .for  the  purpose  of  quieting  the  patient. 


25 

Trional  I  have  tried  with  success  in  many  cases  in  doses  of  from  15 
to  30  grains,  also  sulphonal,  tetronal  and  hydronal.  Fhiid  extract  of 
Jamaica  dogwood  is  said  to  be  of  value,  but  personally  I  have  never  seen 
its  value.  I  have  frequently  received  surprising  results  from  the  use  of 
bromide  of  potassjum  in  10  grain  doses.  Next  to  opium  I  rely  on  this.  I 
have  never  received  any  assistance  f  rOm  the  coal  tar  antipyretics.  You  will 
find  in  the  literature  men  recommending  these  for  the  purpose  of  allay- 
ing nervous  irritation,  but  personally  I  have  received  no  benefit  from  them. 

ntanasemcnt  of  Sensitive  Dentine. 

Locally,  i.  e.,  to  the  cavity  itself.  Have  the  cavity  perfectly  dry. 
Never  attempt  to  excavate  a  sensitive  cavity  without  the  rubber  dam  on. 
Use  warm  air  and  alcohol  to  assist  you.  Use  only  sharp  burs,  and  if  you 
have  teeth  to  be  filled  just  try  the  experiment  of  having  the  operator  use 
a  dull  bur  and  a  sharp  one,  and  note  the  difference  in  the  amount  of  pain 
they  induce.  Have  your  excavators  sharp,  avoid  overheating  and  make 
no  false  moves,  but  make  each  stroke  count.  When  you  are  not  going 
to  hurt  say  so,  and  when  you  are  tell  the  patient :  "This  will  hurt  a  little 
bit ;  I  will  be  careful,  and  it  will  be  only  for  a  moment." 

Obtundents. 

For  purposes  of  obtunding  the  sensitiveness  in  the  cavity  many  sub- 
stances have  been  used.  Once  upon  a  time  men  used  arsenous  acid,  seal- 
ing it  for  twelve  hours,  but  all  those  pulps  died.  Then  came  the  use  of 
chloride  of  zinc,  which  is  still  used  by  applying  the  crystals  directly  to  the 
cavity  and  allowing  to  liquefy  in  the  cavity,  i.  e.,  allowing  the  crystals 
to  absorb  sufficient  moisture  to  become  liquid,  leaving  it  tor  fifteen  minutes 
or  so.  This  frequently  assists  greatly.  You  must  not  use  chloride  of 
zinc  when  your  pulpal  wall  is  very  thin,  or  too  near  the  pulp.  The  next 
agent  which  was  used  is  nitrate  of  silver.  This,  perhaps,  is  as  efficient 
as  any  agent  we  have,  but  because  it  discolors  the  teeth  it  cannot  be  used 
inany  anterior  teeth,  and  I  never  like  to  use  it  in  a  cavity  at  all,  except 
in  children's  teeth,  of  which  I  will  speak  later.  But  around  sensitive  mar- 
gins in  the  posterior  teeth,  where  no  actual  decay  occurs,  it  is  of  value. 
The  method  that  I  employ  of  using  it  is  this :  I  make  my  solution  fresh 
each  time,  making  a  saturate  solution  of  nitrate  of  silver  in  sterilized 
water.  Then  I  take  an  orangewood  or  rosewood  stick,  whittle  it  flat  like 
a  spatula,  then  dry  the  surface  to  which  it  is  to  be  applied,  dip  the  point 
of  this  stick  in  the  solution  and  rub  it  back  and  forth  over  the  sensitive 
part,  doing  this  four  or  five  times,  and  avoid  getting  it  on  the  soft  tissue. 
I  find  that  to  be  a  very  efficacious  method.  Others  crystallize  this  nitrate 
of  silver  on  the  point  of  a  platinum  wire,  and  then  allow  the  moisture  to 
remain  on  the  surface,  rubbing  this  point  over  the  moist  surface.     Others 


26 

use  it  by  making  thpir  saturate  solution  and  then  cutting  little  squares  of 
asbestos  or  blotting  paper.  This  blotting  paper  I  had  prepared  tor  the 
infirmary  as  far  back  as  1892,  and  I  am  surprised  to  have  someone  bring 
it  forward  as  an  original  notion  of  his.  When  you  wish  to  use  it,  allow 
the  surface  to  be  moist,  and  take  up  this  little  piece  of  paper  and  rub  it 
back  and  forth  over  the  surface.  That  is  a  very  nice  way  to  have  it  for 
purposes  of  applying  it  to  the  soft  tissue  where  you  want  to  burn  out  a 
mucous  patch,  little  ulcers  that  occur  on  the  tongue  and  around  inside  the 
lip  that  are  painful.  But  I  have  got  in  the  habit  of  using  it  in  the  method 
spoken  of  first.  Others  use  a  silver  wire  and  dip  it  into  nitric  acid, 
forming  their  nitrate  of  silver  direct. 

Now,  care  must  be  taken  in  using  these  preparations  not  to  get 
ihem  over  the  soft  tissue  as  it  will  burn  the  tissue  wherever  it  touches. 
If  accidents  do  occur  with  this,  what  is  the  thing  to  do?  Use  salt  and 
water,  forming  a  comparatively  insoluble  chloride  of  silver,  and  you 
have  corrected  the  harm  the  quickest  way  you  can.  When  the  sur- 
faces are  badly  discolored  from  its  use,  and  for  any  reason  you  wish  to 
bleach  it,  use  a  solution  of  cyanide  of  potash,  or  another  way  is  to  paint 
the  discolored  surface  several  times  with  the  tincture  of  iodine,  rubbing 
it  back  and  forth  until  the  iodine  has  actually  cut  the  stain ;  then  bleach 
your  iodine  with  ammonia. 

Absolute  alcohol  is  a  valuable  obtundaht.  It  should  be  applied  di- 
rectly to  the  cavity  with  a  fine  spray  and  continued  for  a  few  minutes. 
The  benefits  derived  are  due  to  the  extreme  dryness  caused.  A  mixture 
of  ether,  chloroform  and  alcohol  is  valuable  used  in  a  similar  manner. 
Ether,  chloroform,  alcohol,  menthol  in  equal  parts  has  been  suggested 
as  a  valuable  obtundant.  This  mixture  should  be  used  in  an  especially 
made  compressed  air  atomizer.  A  very  fine  spray  is  what  is  needed  and 
should  be  directed  into  the  cavity  while  excavating  or  burring.  Rhigo- 
line,  a  light  petroleum   ether,   has  been   recommended.     Ethel   chloride. 


27 

which  is  sold  under  many  names  by  different  firms,  is  a  valuable  remedy. 
It  comes  to  us  in  a  special  container  made  of  thin  glass  or  metal,  with 
a  stop  screw  so  arranged  that  it  can  readily  be  opened  when  the  heat 
of  the  hand  will  cause  a  fine  spray  to  spurt  out ;  this  spray  should  be 
directed  into  the  cavity  a  few  moments  before  beginning  work  and  re- 
peated frequently  while  excavating.  Fig.  8.  All  of  these  ether  mix- 
tures obtund  the  sensitive  dentine  by  their  excessive  drying  action  and 
also  by  the  extreme  cold  the}^  cause,  and  therefore  some  care  must  be 
exercised  in  order  to  avoid  pain  while  using  and  death  of  pulp  as  a 
final  result. 

Carbolic  acid  applied  warm  to  the  cavity  will  often  prove  helpful. 

Cocain,  used  in  connection  with  ether,  is  of  value,  and  also  used 
under  pressure  in  a  similar  manner  is  applied  for  immediate  extirpation 
of  pulps.  That  cocain  used  under  pressure  will  obtund  sensitive  dentine 
there  can  be  no  doubt,  but  the  after  effect  upon  the  pulp  is  a  matter 
still  to  be  determined. 

Cocain  citrate  sealed  in  the  cavity  for  24  hours  sometimes  proves 
helpful.  Many  operators  inject  one  per  cent,  cocain  hydrochiorate  solu- 
tion into  the  gum  tissue  the  same  as  for  tooth  extraction,  which  will 
often  prove  helpful.  Recently  it  has  been  suggested  that  nitrous  oxide 
be  administered.  The  Hurd,  Clark  and  Tetter  inhalers  have  been  made 
for  the  purpose.  The  plan  is  to  have  the  gas  given  by  way  of  the  nose 
and  not  to  completely  anesthetize  the  patient;  but  just  enough  is  given 
to  produce  sem.i-consciousness,  which  condition  can  be  maintained  for 
several  minutes,  during  which  time  the  excavation  is  completed.  The 
author  has  never  had  much  success  with  this  method.  The  difficulty  of 
preventing  the  patient  taking  air  through  the  mouth  and  maintaining 
dryness  while  working,  added  to  the  dislike  patients  have  for  taking  the 
gas  seems  to  indicate  that  the  plan  will  never  be  generally  adopted. 

Hemicranin  dissolved  in  nitrous  ether  sealed  in  the  cavity  for  a 
few  minutes  will  often  prove  helpful. 

In  concluding  this  subject  I  wish  to  emphasize  the  importance  of 
working  with  precision  and  decision,  using  sharp  instruments,  and 
when  possible  cutting  the  fibrils  a  little  way  from  their  terminations  par- 
ticularly in  labial  and  buccal  cavities,  absolute  dryness  is  essential  ta 
success. 

When  all  has  been  said  the  fact  remains  that  some  cases  present 
that  will  not  yield  to  any  measures  suggested,  and  it  is  my  teaching- 
not  to  attempt  the  impossible.  If  permanent  operations  cannot  be  made 
without  too  much  suffering  then  by  all  means  do  temporary  work  and 
have    it   so   understood.      When   cavities    are    filled    with    oxyphosphate 


28 

cement  for  a  year  or  so  the  fibrils  lose  their  sensitiveness,  when  perma- 
nent fillings  can  more  easily  be  made. 

tbermal  Sensitiveness. 

The  tooth  pulp  is  peculiarly  sensitive  to  thermal  changes.  Everyone 
has  had  the  unpleasant  experience  of  allowing  ice  water  to  come  sud- 
denly in  contact  with  the  teeth.  The  sensation  is  always  one  of  pain 
more  or  less  severe  according  to  the  condition  of  the  pulp.  Normally 
the  pulp  responds  in  this  way  to  excessive  changes  of  temperature  and 
cannot  differentiate  between  heat  and  cold.  Within  reasonable  bounds 
this  is  normal,  but  under  certain  conditions  it  becomes  hypersensitive  to 
these  changes — the  slightest  elevation  or  reduction  of  temperature  pro- 
duces pain,  and,  while  this  is  unpleasant  to  the  patient,  it  is  sometimes 
of  diagnostic  aid  to  us,  to  Which  I  shall  refer  in  another  chapter.  When 
such  conditions  present  you  may  feel  very  certain  that  changes  are 
going  on  in  the  pulp  itself.  There  is  present  a  pathological  condition 
and  at  least  the  beginning  of  hyperemia  of  the  pulp,  which  is  the  subject 
of  another  chapter.  All  I  wish  to  say  here  in  this  connection  is  that 
there  is  an  injury  to  the  blood  vessels  of  the  pulp  accomplished  by  trau- 
matic or  chemical  irritation  through  the  fibrils  and  odontoblastic  cells 
as  a  rule,  but  may  be  brought  on  by  a  variety  of  things — the  clearest 
statement  I  find  on  this  point  is  in  Dr.  Black's  lectures,  page  216,  which 
is  as  follows :  "Thermal  sensitiveness  is  liable  to  be  aroused  in  many 
different  ways.  I  have  suffered  from  it  myself  occasionally  in  my  incisor 
teeth  from  its  being  aroused  from  heat  of  a  cigar  in  smoking,  so  much  so 
that  I  had  to  either  cease  smoking  or  protect  the  teeth.  It  may  be  caused 
suddenly  by  an  extraordinary  exposure  to  cold,  as  ice  water.  It  may  be 
caused  suddenly  by  exposure  to  hot  drinks,  and  the  dentist  may  develop  it 
suddenly  by  the  heat  of  the  disc  in  finishing  a  filling  or  the  heat  of  a 
bur  in  excavating,  in  any  tooth  that  has  a  living  pulp.  Often  the  ther- 
mal sensitiveness  is  aroused  during  the  progress  of  decay,  especially  when 
the  decay  has  reached  the  neighborhood  of  the  pulp  of  the  tooth,  and  the 
patient  will  have  paroxysms  of  pain  continuing  longer.  This  continua- 
tion of  the  paroxysms  of  pain  marks  the  severity  of  the  case,  and  finally, 
if  it  continues  to  grow  worse,  the  patient  will  have  pain  when  lying  down, 
will  have  pain  at  night;  the  difference  in  blood  pressure  between  the 
horizontal  position  and  the  upright  position  wlill  be  sufficient  to  deter- 
mine a  condition  of  pain.  They  will  become  sensitive  as  that.  I  have 
seen  cases  in  which  throwing  of  a  stream  of  water  on  the  tooth  three 
degrees  off  either  way  from  the  normal  temperature  of  the  body  would 
induce  excruciating  pain.  In  the  management  of  cases  it  is  the  utmost 
importance  that  we  recognize  what  may  occur,  and  due  caution  in  regard 


29 

to  running  disks  dry,  or  even  in  running  them  wet  we  may  sometimes 
produce  too  much  heat,  or  running  burs  too  long  in  excavating,  or  any 
of  these  things  that  are  calculated  to  produce  heat  which  may  suddenly 
precipitate  a  condition  of  hyperemia  of  the  pulp  or  thermal  sensitive- 
ness. 

What  will  we  do  for  it?  There  is  only  one  thing  to  do,  and  that  is 
to  protect  the  case  as  absolutely  as  possible  from  thermal  changes  until 
it  recovers.  That  may  be  done  in  various  wavs.  In  some  of  the  worst 
cases  I  have  put  caps  of  gutta-percha  over  the  teeth  involved,  covering 
them  in  completely,  particularly  with  persons  who  must  be  out  in  the 
cold  air,  and  where  I  could  not  otherwise  induce  persons  to  protect 
them  from  thermal  changes.  The  patient  himself,  or  herself,  may  pro- 
tect the  teeth  from  thermal  changes ;  they  may  avoid  cold  or  hot  drinks ; 
they  may  avoid  cold  or  hot  foods ;  they  may  avoid  breathing  from  the 
mouth,  and  in  this  way  protect  the  teeth,  and  it  is  very  much  the  best 
way  to  protect  them  from  thermal  changes.  If  we  put  gutta-percha 
caps  over  the  teeth  they  will  be  very  annoying,  and  it  is  often  difficult  to 
induce  patients  to  wear  them. 

Cases  of  very  severe  thermal  sensitiveness  will  get  well  if  properly 
protected,  generally  promptly,  within  a  week  or  ten  days.  Sometimes, 
however,  it  may  require  more  time,  and  wherever  we  find  them  devel- 
oped to  any  extraordinary  degree,  so  as  to  be  very  annoying,  we  should 
desist  from  all  operations  upon  that  tooth  except  those  calculated  to 
mitigate  this  condition.  If  it  has  occurred  from  a  cavity  of  decay  it  is 
best  to  remove  all  decayed  dentin  completely,  so  as  to  remove  the  irrita- 
tion caused  by  the  irritants  in  the  decaying  mass.  When  the  cavity  is 
prepared  do  not  make  a  filling,  but  make  a  temporary  filling  of  gutta- 
percha, and  be  sure  you  make  a  tight  filling.  Have  the  walls  dry  first, 
and  moisten  them  with  eucalyptol,  so  as  to  have  your  gutta-percha 
adhere  and  make  your  filling  tight.  This  is  the  best  treatment,  for 
gutta-percha  is  the  best  non-conductor  we  have  with  which  to  make  these 
temporary  fillings.  A  gold  filling  at  that  time  would  be  the  worst  thing 
that  could  be  done.  Then  await  the  cure  of  this  condition  before  making 
any  other  operations  upon  that  tooth,  and  if  it  is  severe  avoid  any  opera- 
tions whatever  in  the  mouth  until  that  tooth  shall  have  recovered,  or  at 
least  any  operations  that  are  not  absolutely  necessary  at  the  time. 

Now,  this  condition  often  ends  in  death  of  the  pulp  from  strangula- 
tion or  infarction.  Today  the  tooth  may  be  extremely  sensitive  to  ther- 
mal changes ;  tomorrow  the  pulp  may  be  dead,  and  this  sensitiveness 
may  have  disappeared  completely.  The  sudden  disappearance  of  this 
thermal  sensitiveness  marks  very  certainly  the  death  of  the  pulp,  and 
when  the  pulp  of  a  tooth  has  died  under  these  conditions  it  is  of  extra 


30 

importance  that  we  get  the  pulp  out  as  quickly  as  possible.  When  recov- 
ery is  complete  in  these  cases  it  is  usually  by  the  pulp  receding  from  the 
point  of  irritation  and  depositing  through  the  odontoblasts  a  layer  or 
layers  of  secondary  dentine. 


CHAPTER  IV. 

Constructive  Diseases  of  tbe  Pulp. 

Secondary    Dentine    and    Pulp    Nodules.      Causation.      Pulp    Nodules.      Symptoms. 
Calcific  Degeneration  of  the   Pulp. 


Seconaary  Dentine  ana  Pulp  nodules. 

By  the  term  secondary  dentine  is  meant  dentine  formed  about  the 
walls  of  the  pulp  chamber  abnormally.  Pulp  nodules  is  a  term  used  to 
define  irregular  masses  of  calcic  material  occurring  within  the  pulp  tis- 
sue. These  appear  to  be  slightly  different  phases  of  the  same  process. 
The  pulp  seems  to  throw  out  a  layer  or  layers  of  dentine  or  bony 
substance  resembling  it,  as  a  means  of  protecting  itself  from  the  irrita- 
tion of  encroaching  caries,  erosions,  abrasions,  and  from  the  thermal 
irritation  as  a  result  of  large  metallic,  especially  gold  fillings.  In  the 
majority  of  cases  where  gold  fillings  are  placed  teeth  are  more  or  less 
sensitive  for  some  weeks,  and  only  passes  away  as  new  tooth  material  is 
deposited  in  the  tubuli  over  the  point  of  pulp  exposed  to  such  irritation. 
With  advancing  years  pulp  chambers  become  smaller,  made  so  by  the 
continuous  deposit  of  dentine ;  the  lumen  of  the  tubules  lessens.  This 
process  goes  on  until  the  pulp  is  almost  obliterated  in  extreme  old  age. 


Fig.  9. 
Deposits    of    secondary    dentine.    A,  section   of  an  incisor   showing  caries  at  a  and   secondary 
dentine    at    b;    B,    section    of    secondary    dentine;    a,    pulp    chamber;    b,    b,   secondary    dentine;    c, 
primary   dentine— notice   directions  of   tubules   in    each.      (Black.) 


32 

Within  certain  limits  the  formation  of  secondary  dentine  is  purely  a 
physiological  process,  and  seems  to  be  a  part  of  nature's  scheme  to  pro- 
tect the  pulp,  and  is  deposited  by  the  odontoblasts. 


Fig.  10. 

Secondary  dentine  filling  the  pulp  cliamber  of  an  abraded  cuspid.  A,  part  abraded;  c,  the 
abraded  surface;  rf,  secondary  dentine;  <?,  a  slender  point  of  pulp;  f,  deposits  on  wall  of  canal;. 
g,   deposits  in  pulp   tissue.      (Black.) 


FiR.   11. 
The   same   as   Fig.    10 — magnified   to    show    difference   in   primary  and   secondary   dentine.      D, 
normal  dentine;   b,   secondary;  e,  remains  of  pulp;  /,  small  oval   deposits  in  pulp. 


33 

Secondary  dentine  differs  anatomically  from  normal  dentine,  from 
Avhich  it  can  usually  be  distinguished  by  its  lessened  translucency  and 
changed  direction  of  the  tubules ;  indeed,  the  microscope  will  show  fewer 
tubules  in  the  secondary  than  in  the  normal  dentine,  and  the  line  of 
demarcation  can  easily  be  seen.      (See  Fig.  9.) 

The  extent  of  these  deposits  is  important  to  note.  Some  observers 
think  it  never  progresses  so  far  as  to  completeh'  fill  the  chamber  and 
root  canals  ;  others  have  cited  cases  where  the  entire  canal  seemed  to  be 
filled.  I  have  had  several  cases  where  the  upper  two-thirds  were  com- 
pletely filled  as  a  result  of  wearing  down  the  teeth.  They  were  abraded  a 
considerable  distance  below  the  covering  of  the  normal  chambers.  (See 
Figs.  10  and  11.) 

In  the  molar  teeth  these  deposits  occur  most  peculiarly.  In  some 
instances  sim.ph'  a  small  amount  immediately  under  the  carious  cavity 
only ;  and  in  other  cases  the  deposits  wall  not  only  be  at  that  point  but 
on  the  floor  of  the  pulp  chamber  as  w^ell  when  the  normal  grooves  in  the 
floor  will  be  obliterated.  In  other  cases  the  deposits  will  occur  on  oppo- 
site walls  and  progress  until  the  chamber  proper  is  completely  obliterated 
CFig.  12).  In  still  other  cases  it  will  deposit  in  well  rounded  tumor-like 
masses  held  to  the  wall  by  a  narrow  pedicle. 


Fig.  12. 
A,  outline  of  lower  molar  with  cavity  at   h:  at  a  is  seen  a    large  mass  of  secondary  deposit's: 
B — a,   the    granular    mass    of    secondary    deposits;    h,    a    little   different    form    of    deposits,    and    e, 
cylindrical   form    of   deposits;    c,   growth    from   floor    quite   regular  in    form;    d,    outline   of   cavity. 
(Black.) 


34 

I  have  seen  some  cases  of  one  rooted  teeth  where  the  deposit  occurred 
on  the  walls  of  the  root  canal,  producing-  a  stricture,  as  it  were,  of  the  pulp. 

Causation. 

Very  little  can  be  said  regarding-  the  cause  of  secondary  dentine ; 
much  has  been  written,  most  of  which  is  conjecture.  Reasoning  from  the 
cases  we  know  about  it  would  seem  to  be  due  to  some  mild  form  of  irri- 
tation from  without,  to  which  I  have  previously  alluded,  or  to  some 
trophic  nerve  disturbances.  In  all"  instances  it  seems  clear  that  there 
must  be  a  constantly  recurring  hyperemia  of  a  very  mild  type,  for  in 
all  of  these  cases  of  purely  secondary  dentine  we  get  no  history  of  pain 
of  any  marked  degree,  and  in  most  instances  no  pain  whatever.  The 
clinical  importance  of  these  cases  relates  to  the  fact  that  sooner  or  later 
the  pulp  is  lost,  and  in  case  the  pulp  has  to  be  removed  for  any  cause  it 
makes  the  accomplishment  of  that  end  more  difficult.  This  point  will  be 
referred  to  again  in  the  chapter  on  capping  pulps,  and  also  in  the  chapter 
on  the  management  of  root  canals. 

Pulp  nodules. 

As  before  stated,  they  are  irregular  masses  of  bone-like  substances 
occurring  within  the  pulp  itself.  They  resemble  secondary  dentine  in 
chemical  and  physical  construction,  but  differs  from  it  in  anatomical  char- 
acteristics. They  seem  to  more  nearly  resemble  bone.  They  are  not 
built  by  the  odontoblasts,  but  the  exact  method  of  their  formation  seems 
to  be  in  doubt.  Dr.  Black,  who  seems  to  have  done  most  work  in  study- 
ing out  these  formations,  describes  three  distinct  forms. 

I.  Deposits  of  calcoglobulin,  in  form  resembling  the  other  two,  but 
soft  and  always  found  in  the  inflamed  portion,  usually  just  beneath  the 
odontoblasts.  (See  Fig.  13.)  Some  think  these  are  masses  from  which 
nodules  are  formed. 


-  ^'"v^m. : 


Fig.   13. 
Deposits   of   calcoglobulin   within   the   pulp  tissue. 


35 

2.  Calcospherites — hard  round  bodies  differing  in  size,  but  formed 
in  layers  like  the  onion.  (See  Fig.  14.)  These  seem  to  be  formed  in  any 
portion  of  the  pulp,  and  are  usually  mixed  in  among  the  nodules  and 
sometimes  are  contained  within  the  nodule  itself. 


Pulp  nodules,   tooth  of  a  whale. 


(Barrett.) 


3.  Pulp  nodules,  the  hard  irregular  masses  above  referred  to  and 
illustrated  in  Fig.  15,  occur  throughout  the  pulp  tissue,  but  more  abun- 
dantly in  the  crown  portion,  and  we  are  sometimes  astonished  to  find 
such  large  numbers  of  them  within  a  single  pulp.  One  case  in  my  prac- 
tice I  succeeded  in  removing  66  distinct  nodules,  and  yet  the  tooth  had 
given  very  little  trouble  to  the  patient.  Dr.  Black  is  of  the  opinion  that 
they  originated  within  the  veins  of  the  pulp  and  are  more  abundant  in 
middle  age.  They  seem  to  occur  in  perfectly  sound  and  otherwise  healthy 
teeth. 


-^.^V^^-^V-^SJi^Vv  X 


Fig.  15. 
Pulp  nodules  in   the   central   portion   of  pulp.      (Black.) 

Symptoms. 

Pulp  nodules  may  exist  in  great  numbers  and  give  rise  to  no  dis- 
comfort, as  I  have  often  seen  in  extracted  teeth,  which  have  given  no 


36 

history  of  pain,  and  also  in  cases  where  pulps  were  destroyed  for  bridge 
abutments. 

Then  again  the  pulp  of  a  tooth  may  be  the  seat  of  the  most  excru- 
ciating pain  without  the  least  external  evidence  as  to  cause,  and  when 
the  pulp  is  destroyed  it  is  found  to  be  filled  with  very  small  nodules. 
Reflex  pain  is  very  commonly  associated  with  these  deposits,  and  pulps 
containing  them  become  exceedingly  painful  to  the  mildest  irritation. 
Persistent  neuralgia  with  the  pain  deflected  into  some  distant  organ  or 
part  of  the  head  is  very  commonly  found  to  be  associated  with  these 
deposits.  Indeed,  after  15  years'  experience  in  handling  these  cases  I 
have  come  to  the  conclusion  that  when  these  neuralgic  pains  persist 
about  the  face  and  jaws  and  also  the  ears,  and  I  cannot  find  any  external 
signs  about  the  teeth  as  the  probable  cause,  the  cause  is  the  formation 
of  these  nodules  or  other  deposits  within  the  pulp  chamber  of  some 
tooth  which  can  only  be  located  by  using  all  tests  known,  and  sometimes 
by  cutting  into  the  tooth  and  devitalizing  can  the  fact  be  found ;  although 
hypersensitiveness  to  thermal  changes  or  little  or  no  response  will  often 
aid  in  locating  the  offending  tooth.  Treatment  must  always  be  devital- 
ization and  removal  of  pulp  involved,  which  is  by  no  means  an  easy 
matter  in  many  cases,  requiring  patience,  perseverance  and  weeks  of 
time.     This  will  again  be  alluded  to  in  the  chapter  on  devitalization. 

Calcific  Degeneration  of  tbe  Pulp. 

Calcification  of  the  tissues  of  the  pulp  is  another  problem  presented. 
This  is  a  condition  which  the  pulp  itself,  especially  the  fibrous  tissue, 
becomes  calcified,  resembling  calcifications  occurring  elsewhere  in  the 
body.  It  seems  to  follow  certain  degenerative  changes  in  the  pulp  tissue 
itself,  usually  low  chronic  inflammation.  The  morbid  anatomy  presents 
some  marked  differences  from  that  seen  in  the  nodular  and  dentine  cal- 
cifications. In  this  variety  the  pulp  tissue  itself  seems  to  be  converted 
into  hard  bony  substance,  and  in  the  root  portion  assumes  a  cylindrical 
form  apparently  about  the  fibers.  (See  Figs.  16  and  17.)  In  some  cases 
this  calcification  may  go  on  until  the  whole  central  portion  of  the  pulp 
is  involved,  extending  from  the  crown  chamber  to  nearly  the  apical  for- 
amen. I  have  such  a  specimen  now  where  I  succeeded  in  removing  a 
bony  cone  from  an  upper  cuspid  which  is  nearly  as  long  as  the  root  canal 
and  chamber,  and  is  surrounded  by  a  thin  layer  of  pulp  tissue.  In  this 
case  there  was  no  symptomatology.  Indeed,  in  any  cases  there  does  not 
seem  to  be  any  differentiating  symptoms.  In  concluding  this  chapter  I 
wish  to  cite  a  case  that  came  under  my  observation,  as  follows : 

A  gentleman  about  48  years  of  age  came  to  the  office  complaining 
of  severe  pain  in  the  right  side  of  his  face,  a  sort  of  paroxysmal  pain. 


Fig.   16. 

A,  entire  pulp;   b,  pulp  nodules;   c.   pulp  without  nodules.        (Schlenker.) 


Fig.  17. 
Acute  inflammation  of  the  pulp.     D,  dentine;  P,  pulp;  B,  enlarged  capillary;  C,  calcoglobular 
mass.      (Hopewell  Smith.) 


Examining  his  teeth,  I  could  not  find  any  cause  for  trouble  excepting  that 
the  occlusal  surfaces  of  the  molar  teeth  were  abraded  mechanically,  the 
cusps  were  worn  down.  The  application  of  the  usual  means  of  detecting 
hyperemia    failed   to   detect   any.     I  used  in  his  case  electricity,  together 


38  . 

with  a  liniment  and  massage  to  his  face,  and  it  seemed  to  relieve  him 
somewhat  for  a  time.  By  and  by  these  pains  would  come  with  increasing 
intensity,  so  that  the  muscles  of  the  face  would  undergo  spasmodic  con- 
traction beyond  his  control  entirely.  Well,  he  was  an  individual  who 
wouldn't  bear  much  work  with  his  teeth.  He  was  one  of  those  indi- 
viduals who  didn't  believe  much  in  having  much  done  with  his  teeth  any- 
way, and  consequently  had  neglected  them  until  he  had  lost  a  num.ber  of 
his  molars.  He  decided  on  his  own  hook  when  we  couldn't  find  the  cause 
of  the  trouble,  that  he  would  have  a  certain  one  out,  and  he  went  and  had 
a  lower  second  molar  extracted.  He  brought  the  tooth  back  to  me  and 
I  cracked  it  open.  The  contents  of  the  pulp-chamber  and  the  three  canals 
were  completely  calcified,  so  that  I  removed  it  all  in  one  piece,  a  thing 
which  occurred  in  successive  teeth  of  his  until  five  teeth  went  in  the  same 
way.  I  don't  know  what  the  cause  was.  It  didn't  scarcely  seem  prob- 
able that  the  mechanical  attrition  was  the  cause.  I  rather  think  it  was 
something  of  a  systemic  nature  that  had  to  do  with  it,  but  I  don't  know. 
Hypertrophy  of  pulp  will  be  treated  under  inflammation  of  pulp. 


CHAPTER  V. 

Destructible  Cbanges  in  tbe  Pulp. 

HviJeremia.  '  Causes  of  Active  Hyperemia.     Causes  of  Passive  Hyperemia.     Causes 

of   Hyperemia   of   the    Dental   Pulp.      Painful   Process.      Discoloration. 

Symptomology.      Treatment. 


It  does  not  seem  to  me  desirable  that  I  should  here  go  into  a 
lengthy  explanation  of  the  hyperemic  process  other  than  as  seen  in  the 
tooth  pulp.  Your  studies  in  general  pathology  have  made  you  familiar  with 
this  general  subject,  and  yet  I  think  it  wise  to  present  concisely  the  main 
facts.  For  further  consideration  you  are  referred  to  general  text  books 
on  the  subject  of  pathology  and  surgery.  Hyperemia  is  a  condition  in 
which  there  is  an  increased  amount  of  blood  in  the  part.  When  due  to 
increased  arterial  flow  of  blood  it  is  called  active  hyperemia,  and  when 
^\\^  to  an  obstruction  in  the  flow  of  blood  away  from  the  part,  we  call  it 
passive  hyperemia. 

Causes  of  Jlctit^c  Byvcremia. 

Active  hyperemia  may  be  purely  a  physiological  process ;  unusual 
exercise  of  any  organ  calling  for  increased  nutrition  through  the  circu- 
lation will  cause  a  physiological  hyperemia.  That  is  the  method  by 
which  nutrition  is  supplied.  The  blood  supply  of  the  tissues  and  organs 
of  the  body  is  under  the  direct  control  of  the  vaso-motor  system  of 
nerves ;  when  any  part  is  in  need  of  increased  nutrition  this  fact  is,  as 
it  were,  telegraphed  to  the  centers,  and  at  once  the  arteries  and  capillaries 
relax,  and  an  increased  amount  of  blood  passes  through,  and  so  long  as 
the  normal  physiological  function  is  maintained  in  the  part  we  have  purely 
a  physiological  hyperemia ;  but  if  carried  beyond  this,  and  we  have  a 
considerable  amount  of  blood  with  widely  distended  vessels,  injured  walls, 
etc.j  we  have  a  pathological  hyperemia,  and  the  beginning  of  inflamma- 
tion. Active  h^'peremia  may  be  caused  also  by  disease  of  the  heart,  e.  g., 
over  activity  of  the  heart  or  disease  of  the  arterial  walls,  they  being  too 
relax,  etc. 

€<iu$c$  of  Passive  l^yperemia. 

Active  hyperemia  is  liable  to  become  passive.  After  a  time,  from 
overwork  or  injury  the  veins  fail  to  carry  away  the  blood  as  fast  as  it  is 
supplied ;  there  is  then  a  slowing  of  blood  movement  in  the  part.  The 
vessels'  walls  lose  their  tone  and  the  blood  collects  and  become  stagnant. 
I  mean  by  stagnant  that  there  is  not  sufficient  oxygen  in  it ;  then  we  have 


40 

passive  hyperemia.  We  have  passive  hyperemia  from  still  another  cause, 
namely  infarction,  when  from  any  reason  some  semi-solid  substance,  a 
blood  clot,  calcarious  matter,  an  embolus,  or  what  not,  breaks  away  from 
its  original  moorings  and  floats  into  the  blood  stream  until  it  lodges  in  a 
small  artery,  which  in  turn  collects  other  blood  cells  to  itself,  resulting 
in  complete  or  partial  stoppage  of  the  vessel.  Blood  continues  to  flow  In 
increasing  quantities  to  the  part ;  little  or  none  passes  away ;  then  we 
have  truly  a  pathological  condition,  which  soon  results  in  serious  inflam- 
mation. The  amount  of  blood  stagnant  in  the  part  will  depend  somewhat 
on  the  number  of  anastomosing  branches  in  the  exact  locality.  Infarc- 
tion can  be  artificially  produced.  Let  me  say  that  the  method  used  for 
demonstrating  that  is  to  take  some  of  the  lower  animals,  more  particu- 
larly the  frog.  Conheim,  for  example,  took  little  balls  of  wax,  opened  the 
aorta  and  dropped  these  balls  of  wax  into  it.  Then  as  they  passed  along 
the  circulation  he  lifted  up  the  tongue,  and  could  see  the  balls  of  wax 
stopping  in  the  arterioles  under  the  tongue. 

Illustrating  the  fact  that  when  these  things  that  I  have  spoken  of  as 
an  embolus,  a  little  blood  clot,  or  a  little  calcarious  matter,  or  anything 
of  the  kind  that  has  formed  and  becomes  attached  somewhere,  breaks 
loose  and  floats  down  the  stream,  and  when  it  o'cts  to  where  it  can't  go 
any  farther  it  plugs  it  up,  and  as  a  result  we  have  blood  flowing  to  the 
part  in  an  increased  quantity,  none  going  away,  and  we  have  as  a  result, 
infarction  and  passive  hyperemia.  If  we  watch  the  tissues  under  the 
microscope  during  the  process  and  progress  of  hyperemia  what  do  we 
see?  The  most  common  experiment  is  to  take  the  web  of  a  frog's  foot, 
stretch  it  tightly  across  the  field  of  the  microscope  and  notice  the  blood 
flowing;  you  can  see  it  readily;  then  irritate  the  part  so  as  to  injure  the 
tissue.  First,  you  will  notice  a  slight  contraction,  followed  immediately 
by  distention  of  the  vessels.  The  white  corpuscles  begin  to  hover  around 
the  injured  tissue;  the  vessels  continue  to  distend;  by  and  by  the  serum 
of  the  blood  begins  to  escape  through  the  vessel  wall.  Next,  the  red 
corpuscles  work  their  way  out  into  the  tissue  in  increasing  numbers. 
The  part  becomes  swollen  and  red,  due  to  the  increased  number  of  rd'd 
blood  cells  in  the  tissue,  and  finally  we  have  complete  infarction  and 
stasis.  This  is  the  thing  that  often  occurs  in  the  dental  pulp,  and  it  Is 
exactly  at  this  point  that  we  have  the  beginning  of  inflammation. 

Causes  of  1)yperetiiia  of  tAe  Dental  Pulp. 

First,  and  most  common,  perhaps,  is  a  simple  irritation  of  the  dental 
fibrils.  You  are  all  familiar  with  the  progress  of  decay  into  the  cavity. 
A  small  break  occurs  through  the  enamel,  and  then  underneath  the 
•enamel  a  great  hole  is  burrowed  out,  always  keeping  conical  in  shape.     In 


41 

the  progress  of  this  decay  these  micro-organisms  actually  work  into  the 
dentinal  tubules  and  there  perform  their  function,  i.  e.,  the  function  of 
growth  and  reproduction — the  function  of  nutrition.  They  take  their 
nutrition  first  by  producing  something  to  act  as  a  solvent  of  the  things  to 
be  taken  into  the  system,  in  the  process  of  which  they  evolve  their  irritant 
waste  product,  which  continues  to  irritate  these  fibers,  and  in  turn  the 
odontoblasts  are  irritated,  and  they  in  turn  affect  the  pulp  itself,  which 
calls  for  increased  nutrition  in  the  part;  the  poisons  formed  from  solu- 
tion of  their  dead  bodies  act  in  a  similar  manner.  It  is  a  very  important 
thing  for  us  to  remember  that  these  micro-organisms  produce  irritation 
by  all  of  these  ways.  This  irritation  may  occur  through  abraded  or 
eroded  surfaces  by  the  influence  of  the  irritant  action  of  substances  such 
as  acids,  heat,  cold  or  attrition. 

We  have  another  class  of  cases  where  there  is  no  decay.  Teeth 
apparently  sound  suddenly  become  sensitive  to  thermal  changes.  It  may 
be  caused  by  continued  contact  with  heat,  such  as  the  cigar  or  pipe,  or 
something  of  that  sort,  or  it  may  be  from  some  systemic  disturbance 
which  dilates  the  arteries — hyperactivity  of  the  vaso-dilator  or  vaso- 
constrictor in  the  vessel  wall,  a  thrombus  in  the  circulation,  a  shock  of 
some  kind— all  of  which  may  give  rise  to  hyperemia  of  the  pulp,  and  not 
infrequently,  death.  Sometimes  this  occurs  from  overheating  with  burs 
and  stones,  polishing  strips  and  disks,  as  I  have  stated.  I  think  I  ought 
to  emphasize  that.  It  is  so  easy  to  cause  hyperemia  of  the  pulp  by  exces- 
sive heating  from  our  instruments.  More  particularly  do  I  think  that 
students  are  likely  to  cause  this  by  the  use  of  their  strips,  taking  strips 
and  drawing  them  from  one  end  to  the  other  between  the  teeth,  filing 
down  their  fillings,  in  that  way  causing  excessive  heating  of  the  part,  a 
thing  to  be  avoided.  When  the  pulp  is  irritated  from  such  a  cause  what 
occurs  ?  First,  if  the  irritant  be  of  mild  nature  we  have  a  physiological 
hyperemia,  increased  nutrition  carried  on  and  a  protection  thrown  out 
and  a  drawing  back  of  the  pulp  and  new  dentin  formed,  usually  over  the 
spot  of  irritation,  i.  e.,  irritation  to  the  odontoblastic  layer  and  then  irri- 
tation to  the  pulp  itself;  and  the  pulp  will  gradually  recede  from  this 
irritant,  and  throw  out  through  the  medium  of  the  odontoblasts  a  second 
deposit  of  dentin,  thereby  protecting  the  pulp  tissue  itself  from  the  irritant. 
That  is  nature's  method  of  protecting  the  pulp  from  the  irritant  without. 
Sometimes  this  physiological  process  becomes  diverted  in  some  manner, 
and  we  have  deposits  occurring  within  the  pulp  tissue  itself  which  we 
have  fully  explained  in  Chapter  IV.  If  this  irritation  be  very  sudden  or 
violent,  then  we  have  active  hyperemia  rapidly  becoming  passive,  and 
stagnation,  destroying  the  whole  pulp,  either  by  infarction  or  through 
the  inflammatory  process.     It  is  passive  hyperemia  we  have  to  fear  in  the 


42 

dental  pulp.     In  a  previous  chapter  I  called  attention  to  the  fact  that  the 
pulp-chamber  was  normally  filled  with  pulp  tissue. 

Painful  Process. 

In  extensive  hyperemia  we  have  a  painful  condition,  due  to  the 
swelling  of  the  soft  tissue.  We  have  the  normal  process  going  on  that 
we  have  in  other  tissue,  i.  e.,  the  enlargement  of  the  vessels,  swelling  out 
of  the  tissue ;  the  tissue  being  unable  to  expand  beyond  the  confines  of 
the  pulp  chamber,  of  course  make  a  very  painful  condition,  due  to  the 
pressure  on  all  the  tissue  confined  in  this  canal,  nerve  fibers  and  all.  A 
swollen  or  enlarged  vessel  must  of  necessity  press  upon  those  lying  next 
to  it,  and  thus  we  have  pain,  from  increasing  pressure.  We  find  the  blood 
vessels  become  much  enlarged  under  more  severe  irritation    (Fig.    i8). 


Fig.  18. 
Dilated    blood    vessels    from    a    hyperemic    pulp. 


(Black.) 


and  by  and  by  their  contents  begin  to  escape  into  the  tissue  through  the 
vessel  wall;  not  at  first  through  a  break  in  the  wall,  but  between  the 
cellular  structure  of  it.  First  we  have  the  liquor  sanguinis  and  then  the 
red  corpuscles,  by  their  amoeboid  movement,  as  seen  In  Fig.  20.  Blood 
may  pour  out  in  considerable  quantity  and  form  a  clot  in  the  tissue  and 
yet  recover.  In  these  cases  the  clot  is  carried  away  partly  by  the  process 
of  absorption  and  partly  by  the  leucocytes,  which  are  the  scavengers  of  the 
body,  for  remember  we  stated  that  the  pulp  tissue  has  no  lymphatics. 
If,  however,  this  escape  of  blood  be  too  great  or  for  any  reason  recov- 
ery does  not  ensue,  the  case  is  liable  to  go  through  complete  stagnation 
and  a  whole  mass  of  pulp  die  by  strangulation  or  infarction  at  the  apical 
foramen.  You  will  remember  as  we  approach  the  foramen  the  root  canals 
become  constricted  until  it  is  very  small  at  the  apical  opening,  and  it  is 
in  this  part  of  the  tooth  that  w^e  have  infarction  occurring,  shutting  ofif 
completely  the  circulation  in  the  pulp  itself. 


43 

Discolorations. 

When  the  plup  dies  from  such  a  cause  and  the  mass  of  pulp  remains 
in  the  chamber  a  solution  of  the  coloring  matter  of  the  blood  sometimes 
occurs  and  penetrates  the  dentin,  spreads  to  the  enamel  and  redness  can 
sometimes  be  seen  at  the  neck  of  the  tooth  just  above  the  enamel,  and  the 
whole  color  of  the  tooth  is  changed  darker,  not  that  the  red  corpuscles 
penetrate  the  dental  tubuli,  but  rather,  as  I  have  said,  a  solution  of  the 
coloring  m.atter  wbich  readily  enters  them.  We  shall  refer  to  this  fact 
again  when  we  come  to  talk  about  the  causes  of  discolored  teeth.  I  wish 
to  say  here  that  when  pulps  in  this  condition  die  they  should  be  removed 
immediately  to  prevent  such  discoloration.  Thus  we  have  seen  that  irri- 
tation of  the  dental  fibrils  produces  hypersensitiveness  of  the  pulp.  Heat 
and  cold  cause  increasing  pain  and  add  further  injury,  until  finally  the 
elastic  walls  of  the  vessel  lose  their  tone,  become  greatly  enlarged  and 
more  and  more  blood  escapes  through  the  walls  ;  stagnation  occurs  and 
we  have  the  beginning  of  inflammation.  It  must  be  borne  in  mind  that 
these  eases  often  get  well  under  favorable  treatment. 

Symptomology. 

What  are  the  symptoms  of  hyperemia  of  the  pulp,  and  how  may  we 
learn  to  recognize  it? 

First,  get  a  complete  history  of  the  case ;  find  out  what  caused  the 
pain,  something  about  the  nature  of  the  pain.  In  hyperemic  conditions 
the  pain  is  paroxysmal,  usually  induced  by  hot  or  cold ;  pain  lasting  a 
few  moments,  and  then  all  is  quiet  until  again  irritated.  Patient  notices 
pain  on  taking  hot  or  cold  drinks,  or  even  cold  air.  Unless  the  condition 
be  relieved  the  pain  soon  begins  to  last  longer  each  time ;  now  an  hour, 
perhaps  next  time  two  hours,  and  by  and  by  the  slightest  thermal  change 
produces  the  most  violent  paroxysms.  The  condition  grows  until  death 
or  violent  inflammation  takes  place.  Then,  I  say,  the  first  thing  to  do 
is  to  get  the  history  of  the  case ;  find  out  the  things  that  caused  pain ; 
how  long  the  pain  lasts  when  it  comes,  and  all  that.  Second,  pain  may 
be  slight  during  the  day  when  all  faculties  are  active,  using  the  blood 
supply  for  nutrition  of  the  body  everywhere ;  but  at  night,  when  active 
faculties  are  resting  and  the  patient  is  in  a  recumbent  position,  pain  en- 
sues, due  to  increased  circulation  in  the  injured  vessel,  so  that  it  not  infre- 
quently occurs  that  you  will  have  patients  complaining  that  as  soon  as 
they  go  to  bed  their  tooth  begins  to  ache ;  it  may  not  ache  at  all  in  the 
day  time.  Third,  in  going  from  a  cold  room,  where  the  patient  has  been 
for  some  time,  into  a  warm  room,  pain  increases  ;  or  In  going  from  a 
warm  room  into  a  cold  room  sometimes  pain  increases.  These  are  the 
symptoms. 


44 
treatment. 

What  shall  we  do  to  relieve  them?  First,  when  we  can  locate  the 
cause,  remove  it  and  put  the  part  at  rest.  That  is  the  fundamental  prin- 
ciple in  treating  hyperemia.  The  most  common  cause,  as  I  have  said,  is 
caries.  If  dental  caries  is  the  cause  of  hyperemia  of  the  pulp,  then  we 
must  remove  the  cause,  all  of  it.  We  must  remove  all  the  decay ;  get  it 
all  out.  I  need  to  emphasize  that  fact  because  so  many  neglect  that 
thing.  They  will  excavate  a  cavity  until  they  think  it  is  approaching  the 
pulp,  and  they  leave  a  lot  of  dead,  rotten  material  over  the  pulp  itself 
and  expect  that  pulp  to  get  well.  If  the  micro-organisms  die  and  decom- 
pose there  they  will  poison  the  pulp  effectually,  because  if  you  have  decay 
extending  into  the  pulp  you  have  an  exposure  in  the  sense  of  being  ex- 
posed to  the  influences  of  the  saliva  and  other  substances  present.  Do  not 
leave  decalcified  dentin  that  is  filled  with  micro-organic  life  over  the 
pulp  for  the  purpose  of  avoiding  exposing  the  pulp,  because  if  the  removal 
of  it  would  expose  the  pulp  then  you  have  a  pulp  exposed  already. 
When  we  have  an  actual  exposure  of  the  pulp  in  this  way  we  not  only 
have  hyperemia,  but  we  nearly  always  have  inflammation.  Provided  no 
actual  exposure  occurs,  you  may  treat  the  cavity  with  a  bland,  soothing 
agent,  such  as  oil  of  cloves  and  iodoform. 

Bear  in  mind  that  no  agent  should  be  used  that  will  in  any  way 
irritate  or  poison  the  tissue. 

After  you  have  this  done,  make  a  tight  filling  of  gutta-percha  or 
some  good  non-conducting  material,  avoiding  pressure  upon  the  pulp, 
which  requires  some  care  when  the  pulpal  wall  is  thin.  Then  let  your 
case  rest  until  recovery  is  complete,  when  you  can  make  a  permanent 
filling.  In  some  cases  it  may  require  the  complete  covering  of  the  af- 
fected tooth  with  gutta-percha  for  a  time,  as  previously  referred  to. 
Most  cases  of  this  kind  get  well.  Bear  in  mind  that  I  am  speaking  of 
hyperemia  of  the  pulp,  not  inflammation. 

In  those  cases  where  painful  hyperemia  is  the  result  of  traumatic 
injuries,  overheating  by  instruments,  stones,  burs,  disks,  strips,  etc.,  re- 
sulting in  thermal  sensitiveness,  the  important  thing  to  do  is  to  put  the 
part  to  rest.  Avoid  the  use  of  hot  or  cold  or  other  irritating  things  in 
the  mouth ;  covering  the  tooth  with  a  non-conductor  will  often  be  helpful ; 
in  every  way  protect  the  tooth  against  anything  that  causes  pain  in  a 
given  case — and  recovery  can  be  looked  forward  to  in  a  majority  of  cases 
— and  yet  some  will  die,  and  there  seems  to  be  no  way  of  avoiding  it. 


CHAPTER  VI. 

Destructive  gbanges  eontiiiued. 

Inflammation.     Causes  of  Inflammation.      Symptoms   of   Local    Inflammation.      In- 
flammation  as   a   Reparative   Process.      Conheim's   Theory. 


Tnflatnitiatiom 

Inflammation  may  be  defined  to  be  a  morbid  process  going  on  in 
some  tissue  of  the  body  which  is  characterized,  when  on  the  external  sur- 
face, by  its  heat,  redness,  swelHng  and  pain.  You  readily  see  that  this 
definition  will  also  accurately  describe  hyperemia.  The  first  step  in  the 
inflammation  process  is  hyperemia.  Let  us  return  to  the  web  of  a  frog's 
foot,  which  we  used  to  illustrate  hyperemia.  When  an  irritant  is  applied 
we  see  first  a  slight  contraction  in  the  vessels.  Second,  an  expansion  of 
the  vessels ;  increased  amount  of  blood  in  the  part ;  vessel  walls  become 
inactive ;  the  blood  is  not  forced  on  and  so  continues  to  accumulate.  The 
third  thing  we  see  is  that  the  serum  of  the  blood  begins  to  escape ;  this  is 
not  coagulable ;  coagulable  elements  do  not  yet  escape.  This  escape  is 
made  through  the  vessel  walls  between  the  cells  of  the  endothelial  lining. 
Fourth,  the  peripheral  stream  containing  the  white  corpuscles  begins  to 
slow  until  complete  stasis  occurs,  and  here  is  where  inflammation  begins. 
Inflammation  begins  with  an  exudation  of  coagulable  lymph.  Remember, 
w,e  stated  in  our  study  of  hyperemia  that  the  liquid  sanguinis  which 
escapes  out  into  the  tissue  is  not  coagulable;  but  soon  these  coagulable 
elements  begin  to  escape  out  into  the  tissue,  and  there  we  have  the  begin- 
ning of  inflammation.  The  next  step  in  the  inflammatory  process  is  the 
escape  of  the  white  blood  cells.  They  pass  through  for  four  reasons. 
First,  the  injured  vessel  wall  is  less  resistant.  Second,  the  amoeboid 
movement.  Third,  the  pressure  from  within,  the  force  from  within,  accu- 
mulation of  blood  and  so  on  within  the  vessel  wall  forces  it  out.  Fourth, 
by  its  chemotactic  property.  The  study  of  the  chemotactic  property  of 
cells  is  indeed  one  of  the  most  interesting.  By  chemotactic  property  I 
mean  the  attraction  which  one  cell,  under  certain  conditions,  has  for 
another  cell.  If  you  watch  these  little  white  blood  cells  as  they  go  out 
into  the  tissue  you  really  feel  as  though  they  had  a  separate  intelligence 
capable  of  directing  their  movement.  They  will  wander  about  into  the 
injured  tissue,  carrying  nutrition  and  carrying  away  broken  down  tissue. 
We  have  two  kinds  of  chemotactic  properties — what  is  known  as  the 
positive  chemotactic,  i.  e.,  the  attraction  that  one  cell  has  for  another, 
and  the  negative,  or  the  repellant  action  which  one  cell  has  for  another. 


46 

And  this  is  all  important  in  the  process  of  inflammation.  Bear  in  mind 
that  the  escape  of  the  leucocytes  is  a  distinctive  feature  of  inflammation, 
not  occurring  in  hyperemia.  Then  the  sixth  thing  we  will  see  is  the 
escape  of  the  leucocytes,  going  on  and  on  until  the  whole  region  is  filled 
with  these  cells.     (See  Fig.  19.)     Then  the  next  thing  that  occurs  is  a 


Fig.  19. 
Section   of  tooth   pulp    showing   the   inflammatory   process   along   the    veins   with    diapedesis    ot 
white  blood  cells.      (Black.) 

change  in  the  normal  cell  elements  of  the  part  into  round  cells.  Nowhere 
can  this  be  seen  more  clearly  than  in  the  tooth  pulp,  because  nearly  all  of 
the  normal  cells  are  spindle  or  star  shaped  cells,  so  that  the  change  from 
star  shaped  to  round  cells  can  be  easily  seen  (Fig.  20). 


Fig.  SO. 
Inflammation   of  dental  pulp.     A,  a,  normal  cells;   b,  h,  b,  b,  inflammatory  elements;  c,  cell? 
dividing.      (Black.) 


The  inflammation  I  have  described  up  to  this  point  is  called  simple 
inflammation,  from  which  recovery  may  be  rapid,  much  on  the  same  plan 
as  recovery  is  made  from  hyperemia.     When  these  cells  begin  to  change. 


47 

we  have  a  central  focus  of  inflammation  containing  coagulable  lymph  which 
creates  a  hard  swelling.  Around  that  we  have  oedema,  or  a  soft  swelling, 
and  around  that  a  hyperemic  condition.  Up  to  this  time  w^e  have  no 
suppuration.  Then  if  we  watch  this  still  farther,  the  next  element,  or 
the  eighth  thing  which  I  have  indicated,  is  the  appearance  of  bacteria  in 
the  region  of  injury,  and  we  have  a  contest  ensuing  between  the  new 
reparative  animal  cells  and  bacteria.  Sometimes  the  bacteria  are  com- 
pletely digested  and  carried  away  and  we  have  little  or  no  suppuration, 
but  perhaps  more  often  these  bacteria  get  the  upper  hand,  the  animal 
cells  are  rapidly  broken  down  and  rapid  suppuration  occurs.  I  have 
used  this  description  because  it  more  nearly  represents  what  actually 
occurs  in  the  tooth  pulp  undergoing  the  inflammatory  process.  For  many 
years  there  was  much  discussion  as  to  whether  we  ever  had  infJamniation. 
untJwiit  micro-organisms,  or  whether  w^e  ever  had  suppuration  wdthout 
micro-organisms.  We  certainly  do  have  inflammation  without  micro- 
organisms, as  you  have  seen,  but  never  suppuration  without  them.  In 
the  dental  pulp  they  are  most  frequently  the  cause  of  inflammation. 

Cau$($  of  Tnflammation. 

I  want  to  say  just  a  word  about  the  causes  of  inflammation  in  general. 
We  divide  it  into  two  general  classes — predisposing  and  exciting.  By 
a  predisposing  cause  we  mean  that  condition  of  the  whole  system  which 
so  acts  as  to  reduce  the  resistance  of  the  body ;  impoverished  blood, 
Bright's  disease,  syphilis,  and  other  forms  of  blood  poisoning  are  wdiat  we 
mean  by  predisposing  causes. 

The  second  element,  a  perverted  nerve  supply.  For  som.e  reason 
the  nerve  supply  becomes  perverted  and  does  not  perform  its  functions 
correctly. 

Third,  the  climate. 

Fourth,  the  age. 

Fifth,  lowered  vitality  of  the  cells  of  the  part. 

The  exciting  causes  may  be  simple  irritation,  i.  e.,  mechanical,  as  it 
were,  and  chemical.  Cold,  producing  sudden  changes  in  the  blood  whereby 
it  fails  to  carry  away  its  waste  product,  and  local  poisoning  occurs.  The 
whole  process  of  taking  cold  is  simply  a  process  whereby  the  waste  prod- 
uct of  the  tissue  is  not  carried  away  properly,  and  consequently  the  whole 
system  is  being  poisoned  from  reabsorption.  Chemical  irritations, 
poisons,  etc.,  enter  into  this  process  of  irritation.  Then  heat,  as  burning 
or  scalding,  as  you  all  know. 

Symptoms  of  Cocal  Inflammation. 

Redness. — "This  symptom  is  persistent,  and  is  due  to  hyperemia.  By 
digital  pressure  the  capillaries  can  be  emptied,  but  on  removing  the  pres- 


48 

sure  the  redness  immediately  returns.  The  shade  of  color  depends  upon 
the  freedom  from  obstruction  in  the  vessels,  and  the  rapidity  of  the  cir- 
culation. When  the  color  is  dark  or  purplish  it  denotes  stasis ;  rose-red 
streaks  along  the  tract  of  the  lymph-vessels  indicate  lymphangitis ;  a  dark 
red  tract  along  the  course  of  the  veins  would  point  to  phlebitis ;  while  a 
copper  red  color  would  denote  syphilitic  inflammation. 

Sisuelling. — This  symptom  is  due  to  the  engorgement  of  the  blood 
vessels  of  the  part,  to  exudation  from  the  blood-vessels  and  to  prolifera- 
tion of  cells.  In  acute  inflammation  the  swelling  is  soft ;  in  the  chronic 
forms  it  is  hard.  Swelling  is  especially  marked  in  loose  connective 
tissue. 

Heat. — This  symptom  is  most  marked  at  the  center  or  focus  of  the 
inflamed  area.  It  is  thought  to  be  produced  by  the  increased  rapidity  of 
the  circulation,  and  the  volume  of  blood  in  the  part.  Hunter  taught  that 
the  heat  of  the  part  was  never  above  the  heat  of  the  internal  organs. 
Hunter's  Law  reads  as  follows :  "In  inflammation  the  heat  of  the  part  is 
increased  above  the  normal  temperature  of  the  part,  but  not  beyond  the 
temperature  of  the  internal  organs." 

Pain. — This  symptom  is  persistent,  and  is  increased  by  pressure,  by 
motion  of  the  part  or  by  general  exercise.  Exercise  increases  arterial 
tension,  and  thus  augments  the  pain.  The  pain  is  most  intense  in  dense 
structures,  and  is  mainly  due  to  mechanical  pressure  upon  the  nerve- 
filaments,  and  is  sometimes  reflected  to  regions  remote  from  the  seat  of 
the  inflammation.  Examples  are,  knee  pain  in  hip-joint  disease,  shoulder 
pain  in  hepatitis,  otalgia  in  pulpitis. 

Disturbances  of  Function. — This  symptom  is  marked  in  its  action 
upon  the  secretions,  which  often  become  perverted  or  suppressed.  The 
reflexes  are  generally  exaggerated.  Examples  are  the  tenesmus  of  dys- 
entery, the  strangury  of  cystitis,  the  convulsions  of  teething.  Non-sensi- 
tive parts  become  hypersensitive,  examples  being  the  pain  of  pleurisy, 
peritonitis,  teething,  or  decayed  dentine  in  vital  teeth." — Marshall. 

Tnflammation  as  a  Keparatioc  Prtcess. 

I  stated  that  following  the  escape  of  the  coagulable  lymph  and  leuco- 
cytes out  into  the  injured  tissue  we  see  certain  changes  in  the  normal  cell 
elements  of  the  tissue ;  the  normal,  or  star  shaped  cells  are  converted  into 
round  cells  and  rapidly  increase  in  number  until  the  whole  region  is 
filled.  This  increase  is  brought  about  in  an  interesting  manner.  The 
first  plausible  theory  advanced,  which,  by  the  way,  was  the  theory  adopted 
by  Virchow  and  Bilroth,  explained  the  increase  in  the  number  of  cells  to 
a  proliferation  of  the  cells  in  the  tissue.  The  inflammatory  irritant  causes 
the  cells  to  take  on  an  increased  activity,  attracting  to  themselves  nutri- 


49 

ment  in  unsual  quantity,  and  consequently  growth  and  rapid  multiplica- 
tion  (see  Fig.  20  at  C). 

Cenl)elm'$  theory. 

Conheim  set  aside  this  theory  and  advanced  the  idea  that  leucocytes 
furnished  all  material  in  the  reparative  process.  This  theory  was  gener- 
ally accepted  for  at  least  two  decades.  He  attempted  to  prove  that  the 
cells  of  the  part  did  not  undergo  any  active  change  during  the  inflam- 
matory process  except  degeneration  or  breaking  down.  Conheim  claimed 
that  the  normal  cells  of  the  tissue  took  no  part  whatever  in  the  repara- 
tive process ;  the  only  change  that  took  place  during  the  inflammatory 
process  in  these  cells  was  that  of  degeneration.  The  manner  in  which 
he  attempted  to  prove  this  was  indeed  very  interesting.  For  this  pur- 
pose he  took  the  cornea,  because  of  its  transparency.  When  he  treated 
the  cornea  with  chloride  of  gold  a  most  perfect  network  of  stellate  cells 
appeared  lying  in  the  inter-cellular  substance,  which  suggested  to  him 
that  these  spaces,  i.  e.,  these  inter-cellular  honey-combed  spaces,  fur- 
nished opportunity  for  the  migration  of  these  wandering  leucocytes,  i.  e., 
they  were  able  to  migrate  out  through  this  inter-cellular  substance.  See- 
ing these  apparent  wandering  cells  lodged  therein  he  determined  that  it 
was  a  process  of  passing  through  the  tissue  which  he  saw,  and  conse- 
quently he  believed  that  they  were  the  agents  which  had  most  to  do  with 
the  reparative  process.  The  following  was  his  experiment :  He  drew;  a 
ligature  through  the  bulb  of  the  eye  of  a  rabbit.  In  24  hours  the  trans- 
parent cornea  became  opaque,  due  to  the  increased,  number  of  leucocytes 
which  were  present,  as  shown  by  taking  the  cornea  before  it  became 
opaque  and  examining  it  under  a  high  power.  He  claimed  that  all  the 
new  cells  were  identical  with  leucocytes,  i.  e.,  the  new  cells  that  he  saw 
in  this  cornea.  To  further  -prove  his  point,  he  injected  small  granules  of 
carmine,  held  in  suspension,  into  the  lymph  sacs  and  the  blood  vessels  of 
a  frog;  he  then  produced  his  inflammation  of  the  cornea  and  many  of 
the  new  cells  which  he  found  contained  these  granules,  which,  by  the 
way,  he  was  unable  to  find  anywhere  else  in  the  system.  These  experi- 
ments were  performed  in  1867,  and  they  created  the  most  widespread  dis- 
cussion everywhere.  Scientists  everywhere  were  discussing  this  theory 
of  Conheim's,  and  as  a  result  it  created  a  great  amount  of  opposition. 
Many  men  attempted  to  prove  the  old  theory  of  cell  proliferation,  and 
Strycher,  of  Vienna,  took  up  this  theory  and  advanced  it  still  further, 
and  evolved  his  theory  of  tissue  metamorphosis  in  which  he  claimed  that 
not  only  did  the  cells,  but  the  entire  tissue,  inter-cellular  substance,  etc., 
all  return  to  their  embryonic  condition.  He  took  up  this  theory  of  cell 
proliferation  and  did  an  immense  amount  of  work.     Few  of  us  can  com- 


50 

prehend  the  amount  of  work  these  scientists  did  along  these  lines,  trying 
to  prove  that  not  only  the  cell  elements,  but  the  inter-cellular  substance 
and  all  returned  to  its  embryonic  condition,  from  which  it  rapidly  grew, 
and  separated  into  amoeboid  masses  from  which  new  tissue  was  grad- 
ually developed.  From  that  time  on  men  everywhere  have  been  studying 
this  process. 

Grazvit::'s  theory  was  based  on  the  fact  that  throughout  all  tissue  in 
the  inter-cellular  spaces  are  seen  slumbering  cells,  i.  e.,  the  cells  which 
Conheim  claimed  to  be  leucocytes,  but  which  Grawitz  claimed  were 
really  slumbering  cells,  which  under  certain  conditions  are  capable  of 
waking  up,  as  it  were,  and  undergoing  certain  changes.  By  their  amoe- 
boid movem.ent  they  wander  out  through  the  tissue,  taking  on  active  life. 
At  first  the  slumbering  cells  have  but  a  small  nucleus  and  little  or  no 
protoplasm.  Their  nuclei  gradually  enlarge  and  acquire  a  cell  body  and 
assume  all  the  functions  of  tissue  cells,  with  protoplasm  and  all.  This, 
then,  was  the  cell,  according  to  Grawitz,  which  produced  the  process  of 
repair.  At  the  present  time,  scientists  account  for  the  presence  of  such 
a  large  number  of  cells  in  reparative  inflammations  to  all  three  of  these 
sources.     The  normal  tissue  cells  multiply,  in  three  ways. 


Fig.  21. 
Karyokinesis.      A,    resting  stage;   B,   convolution   stage;    C,  wreath   stage;   D,   monoster   stage; 
E,  lengthening  of  cells  toward  the  poles;   F  and  G,  the  rosette  dividing  into  two  groups;  H,  the 
two   groups   pass   to    opposite    poles;    I,    diaster   stage;    J,    diaster    stage,     with  complete  neuclei;   K, 
convolution   stage,    daughter  cells;   L,   daughter  cells  at  rest. 


51 

First,  By  budding. 

Second,  by  direct  cell  division  (see  Fig.  20,  c). 

Third,  which,  of  course,  is  by  far  the  most  interesting  and  the  one 
that  is  the  most  common,  most  usually  known  as  karyokinesis,  which  I 
have  attempted  to  illustrate  in  Fig.  21.  That  is  the  process  by  which  the 
cell  elements  of  tissue  reproduce  themselves  mostly. 

The  second  element  in  this  inflammatory  process  of  repair,  the  slum- 
bering cells  awaken  into  new  activity.  These  cells  resemble  the  leuco- 
cytes in  appearance,  and  it  is  doubtful  if  one  is  not  taken  for  the  other. 
These  cells  lie  caught,  as  it  were,  in  the  network  composing  the  normal 
tissue.  Many  consider  them  purely  embryonic  cells  left  from  the  em- 
bryonic condition  of  the  tissue.  In  the  growth  and  development  tissue 
maintains  largely  an  embryonic  condition  until  maturity.  During  all  of 
this  developmental  stage  a  greater  amount  of  these  cellular  elements  are 
required  than  after  maturity  is  reached,  consequently,  the  theory  is  that 
this  excess  of  cells  that  have  not  been  used  atrophy  and  are  caught  and 
lie  there  in  the  inter-cellular  spaces — one  of  the  wonderful  provisions 
of  Nature ;  they  are  a  reserve  fjimd,  kept  there  to  be  used  in  time  of  need. 
They  are  used  in  time  of  over-exertion  of  muscular  tissue  and  during 
inflammatory  processes  always.  That  is  the  second  element  as  seen  in 
tissue  repair. 

I  stated  that  when  they  are  first  seen  they  scarcely  seem  to  have 
even  a  nucleus — simply  a  small  speck,  with  no  protoplasm.  When  they 
are  brought  into  action  they  gradually  enlarge  their  nucleus  and  take  on 
forms  of  protoplasm.  Protoplasm  furnishes  the  means  of  carrying,  shall 
I  say  food,  to  build  up  the  waste  tissue. 

Then  the  third  element  that  we  account  for  in  this  process  of  repair 
from  inflammation — the  leucocytes  normally  floating  in  the  blood  stream 
are  attracted  there  for  reparative  purposes.  They  bring  fresh  nutriment 
and  more  especially  carry  away  useless,  broken  down  material,  waste  tis- 
sue, etc. ;  that  is  the  greatest  function  of  these  leucocytes  which  normally 
float  in  the  blood  stream.  What  other  function  they  perform  we  at 
present  haven't  a  clear  idea.  We  thought  we  had  a  few  years  ago,  but 
that  whole  notion  has  been  changed  now.  There  is  an  actual  increase  of 
white  blood  cells  during  inflammation,  not  only  out  in  the  injured  tissue, 
but  also  in  the  whole  blood  stream.  The  whole  system  thus  appears  in 
sympathy  with  the  injured  tissue  and  those  organs  in  which  the  white 
blood  cells  normally  abound  and  perhaps  have  most  to  do  with  their 
formation — especially  the  spleen  and  lymphatic  glands — are  much  en- 
larged during  the  process  of  severe  inflammation,  due  to  reflex  action 
from  the  injured  arterioles.  The  greater  the  injury,  the  larger  the  num- 
ber of  cells.     Slight  inflammations  require  but  a  few  in  the  process  o£ 


52 

repair  and  Nature  provides  but  few.  Severe  inflammation  and  suppura- 
tions requirmg  more,  Nature  provides  more.  Those  white  blood  cells 
which  have  to  do  with  the  carrymg  of  food  material,  so  to  speak,  and  the 
carrying  away  of  waste  material,  we  call  phagocytes.  The  most  interest- 
ing process  taking  place  in  the  animal  body  is  that  of  metabolism.  All 
higher  forms  of  life  are  but  many  simple  cells  so  arranged  as  to  form  a 
structural  unit.  These  cells  are  only  capable  of  growing  under  favorable 
-conditions.  The  whole  mechanism  of  the  body  is  a  unit  of  cell  collec- 
tions ;  in  order  for  these  cells  to  grow  and  perform  their  function,  they 
must  have  food;  they  must  grow  and  reproduce  themselves.  You  can 
readily  see  that  if  these  cells  did  not  constantly  reproduce  themselves  the 
whole  body  would  soon  die  out. 

Third,  they  form  waste  products  which  must  be  secreted.  When  food 
is  taken  into  the  stomach,  having  previously  been  acted  upon  by  the 
saliva,  it  is  further  acted  upon  by  the  gastric  juices,  and  part  of  it,  which 
is  now  ready  for  absorption,  passes  directly  into  the  blood  through  the 
walls  of  the  stomach.  The  remainder  passes  on  to  the  intestines,  and  is 
there  again  acted  upon  and  absorbed  directly  into  the  iacteals ;  from  there 
into  the  blood.  This  blood  is  then  taken  to  the  lungs  and  to  the  liver, 
respectively,  and  then  passes  directly  to  the  tissue.  Each  time  it  enters 
the  blood  it  unites  into  chemical  combination  with  the  protoplasm  of  the 
cells. 

The  process  by  which  all  of  this  is  carried  on  is  a  chemical  process 
pure  and  simple,  and  when  the  blood  passes  through  the  lungs  it  adds 
oxygen,  as  you  know,  and  we  have  a  highly  complex  substance  of  many 
chemical  elements  united  in  such  a  way  as  to  be  readily  exchanged  into 
cell  tissue.  At  the  present  time  the  chemistry  of  the  proteid  molecule  is 
poorly  understood.  There  is  room  for  some  of  you  gentlemen  to  do  some 
splendid  work  along  that  line,  and  it  is  the  only  thing  we  need  now  -to 
perfect  us  in  m.any  lines  of  medication.  Just  as  soon  as  we  are  able  to 
know  definitely  the  chemical  combination  of  this  proteid  molecule,  just 
so  soon  will  we  be  able  to  know  what  substance  we  can  administer 
that  will  chemically  unite  with  it  to  change  it  in  the  direction  we  wish  it 
changed.  The  process,  then,  by  which  this  nutrition  is  taken  up  in  the 
cell — the  phagocytes  bring  this  material  in  its  most  absorptive  form,  the 
form  in  which  it  can  be  most  readily  used  by  the  cells  of  the  tissue.  Then 
by  the  process  which  I  spoke  of  as  the  chemotactic  property,  cells  in  cer- 
tain conditions  are  attracted  to  cells  in  certain  condition,  chemically.  The 
phagocytes  containing  certain  chemical  elements  are  attracted  to  the  tis- 
sue cells  containing  certain  chemical  elements.  These  chemical  elements 
are  constantly  changing  in  the  tissue  cell,  as  well  as  in  the  phagocytes. 
The  process  of  wear  on  tissue  cells  is  a  chemical  process.     Fatigue  is  a 


53 

chemical  process  in  the  cehs  themselves.     We  are  just  beginning  to  real- 
ize this,     it  is  the  all  important  phase  of  physiological  chemistry. 

The  waste  products  that  these  cells  form — speaking  now  of  the  tis- 
sue cells — has  to  be  carried  away.  The  waste  product  is  largely  urea  and 
uric  acid,  and  one  of  the  functions  of  this  phagocyte  is  to  exchange  its 
nutriment  for  the  waste  product  of  the  tissue  cells.  It  is  carried  away  by 
way  of  the  kidneys  and  excreted  in  the  form  of  urea,  and  excreted 
partly  by  way  of  the  lungs  in  the  form  of  carbonic  acid.  That  is  the 
whole  chemical  philosophy  of  the  system,  and  nutrition  is  purely  a  chem- 
ical process.     I  hope  I  can  firmly  impress  that  upon  your  minds. 

I  think  I  have  said  sufficient  to  enable  you  to  follow  my  further 
illustrations.  Take  a  simple  incised  wound.  The*  edges  are  covered 
over  with  this  coagulable  exudate  and  clot,  rich  in  album.en.  I  might  say. 
that  in  olden  times  the  surgeon  was  governed  in  his  treatment  of  these 
wounds  by  the  presence  of  this  coagulable  exudate  upon  the  surface  of 
his  incised  wound.  He  waited  until  that  appeared,  as  he  thought,  good 
and  healthy,  then  he  brought  his  wound  together,  believing  thereby  that 
he  would  cement  the  wound  by  bringing  these  two  coagulable  exudates 
together.  Of  course,  the  method  which  we  now  follow  is  to  bring  our 
incised  wound  in  direct  opposition.  If  we  can  do  that  we  have  our  slight 
exudate  forming,  filling  in  the  mechanical  defect.  Then  these  cells 
abounding  in  this  exudate,  being  transformed  into  embryonic  tissue  grad- 
ually change  into  permanent  tissue  form,  into  which  we  have  the  little 
vessels  sprouting  out,  as  it  were  following  out  into  the  tissue  itself,  until 
finally  the  blood  vessels  unite  on  opposite  sides  and  we  have  the  circula- 
tion re-established,  and  lastly  we  have  the  epithelium  growing  out  and 
covering  over  the  wound.  Take  a  wound  Avhere  a  large  surface  is  in- 
volved, where  it  is  not  possible  to  bring  all  the  surfaces  of  the  wound 
together ;  the  healing  process  is  brought  about  by  the  building  up  of  this 
embryonic  tissue  from  the  bottom  until  the  whole  tissue  is  filled  up ;  then 
we  have  the  epithelium  reproducing  itself,  quite  in  the  same  manner 
that  ice  freezes  over  a  pond,  first  beginning  at  the  circumference,  then  a 
little  farther  in  and  so  on  until  finally  it  covers  over  the  whole  mass.  All 
of  these  cells,  of  course,  as  the  change  is  made  from  embryonic  to  per- 
manent tissue,  assume  the  spindle  shaped  form  and  become  fully  organized 
into  fibrous  tissue.  The  first  process  that  I  outlined  to  you  is  what  is 
known  as  healing  by  first  intention. 

Chronic  inflammation  is  a  condition  in  which  we  have  the  symptoms 
of  acute  inflammation,  but  to  a  less  degree.  It  usually  follows  an  acute 
attack,  and  may  continue  for  years  without  much  apparent  change. 
Usually  the  tissue  hypertrophies— we  have  fungous  growths,  elephant- 
iasis, tumors,  etc.,  but  more  frequently  is  the  end  of  acute  inflammation 
and  passes  directly  into  suppuration. 


54 
treatment  of  Tnflammatioiu 

General  Considerations. 

The  first  principles  in  the  treatment  of  any  inflammation  is  to  remove 
the  cause  and  to  put  the  part  to  rest.  If  the  cause  be  systemic,  then  we 
must  have  that  corrected  first ;  if  due  to  irritation  of  any  kind  that  must 
be  removed.  This  irritation  may  be  of  such  a  nature  as  to  require  sys- 
temic medication ;  indeed,  in  all  severe  inflammations  the  eliminative 
organs  should  all  be  stimulated.  The  bowels  and  kidneys  should  receive 
special  attention  as  well  as  the  skin.  In  addition  to  administering  ca- 
thartics, diuretics  and  diaphoretics,  the  frequent  sponging  the  surface  of 
the  body  with  tepid  water  and  drinking  large  quantities  of  water  will 
prove  most  valuable.  The  application  of  ice,  cold  water,  either  sprays  in 
the  early  stages  of  inflammation  before  stasis  has  occurred,  especially 
where  heat  and  redness  is  pronounced,  is  considered  most  potent  for 
good. 

Heat  in  the  form  of  compresses  wrung  out  of  hot  antiseptic  solu- 
tions, changing  as  often  as  they  become  cool,  is  a  very  excellent  method 
of  stimulating  the  collateral  circulation  and  relieving  the  pain.  When 
the  pain  is  severe  it  may  be  necessary  to  resort  to  the  use  of  some  of  the 
coal  tar  derivative  anodynes,  narcotics  or  opiates.  What  is  meant  by  put- 
ting the  part  to  rest  is  best  illustrated  in  the  prevention  of  occlusion  of  a 
tooth  that  has  becom.e  sore  from  pericementitis  or  excluding  the  light 
from  an  inflamed  eye.  Among  the  other  local  measures  that  are  of  value 
blood  letting,  scarifying,  cupping,  the  use  pf  leeches  and  the  application 
of  counter  irritants,  are  suggested,  especially  over  deep  seated  inflam- 
mations. When  the  blood  pressure  is  high  and  the  pulse  very  rapid  the 
use  of  circulatory  depressents  are  indicated. 

Symptoms  of  Inflammation  of  the  tooti)  Pulp. 

There  are  no  special  symptoms  of  inflammation  of  the  tooth  pulp ; 
they  are  those  of  hyperemia  in  a  more  aggravated  form,  the  paroxysms 
of  pain  last  longer  and  are  more  intense.  We  have  some  difficulty  in 
making  a  differential  diagnosis  of  inflammation  because  we  cannot  see 
the  swelling,  the  redness,  etc.,  that  we  can  see  on  external  surfaces  in 
the  soft  tissue.  Pulps  often  become  inflamed,  suppurate  and  die  without 
any  pain  whatever.  In  hyperemia  there  is  no  tissue  change.  All  the 
cells  in  the  tissue  are  unchanged,  except  the  walls  of  the  vessel ;  while 
in  inflammation  all  the  changes  are  taking  place  as  I  have  described, 
namely,  the  presence  of  coagulable  lymph,  the  white  cells  out  in  the  tis- 
sue, etc.  Up  to  this  point  recoverv  is  nossible,  and,  indeed,  this  stage  is 
about  the  healing  process  of  all  simole  inflammations,  such  as  the  healing 
of  surgical  wounds.    Remember,  simple  inflammation  is  aWays  a  repara- 


55. 

tive  process.  All  tissue  injury  is  healed  by  this  process,  which  is  purely 
physiological.  Inflammation  of  the  tooth  pulp  occurs,  after  that  organ 
is  exposed,  either  from  decay  or  other  cause.  More  frequently  it  is  caused 
by  caries  that  has  penetrated  to  the  pulp,  or  at  least  the  poisons  of  micro- 
organisms in  the  carious  cavity  penetrating  to  the  pulp.  We  doubtless 
do  have  inflammation  of  the  pulp  without  micro-organisms  being  pres- 
ent in  the  tissue,  as  we  have  simple  inflammation  anywhere.  It  is  not 
always  possible  to  tell  just  where  we  have  hyperemia  conditions  and 
where  we  have  inflammation.  We  can  only  decide  as  we  work  at  the 
cavity,  removing  the  carious  dentin.  We  may  have  only  a  slight  por- 
tion undergoing  the  inflammation  process  immediately  around  the  point 
of  exposure,  and  the  rest  of  the  pulp  remain  practically  healthy,  perhaps 
a  little  hyperemic  immediately  around  the  point  of  inflammation.  But 
as  time  goes  on  and  exposure  to  saliva  and  micro-organisms  continues, 
we  will  see  the  inflammation  spreading  in  the  direction  in  which  the 
poison  is  carried  by  the  circulation. 

By  and  by  suppuration  occurs ;  not  in  all  cases.  Some  exposed 
equally  long  do  not  suppurate ;  due,  doubtless,  to  the  condition  of  the  cells 
of  that  organ,  and  perhaps  som.ewhat  to  the  nature  of  the  irritant.  This 
will  be  referred  to  under  the  head  of  suppuration.  After  securing  the 
history  of  the  case  we  must  depend  upon  what  we  find  when  opening  the 
cavity,  to  determine  our  condition.  Does  decay  penetrate  the  pulp  cham- 
ber? If  so,  we  have  a  real  exposure.  What  is  the  condition  of  the 
decay  ?  Is  it  black,  hard,  dead  decay  in  which  the  former  life  has  died 
and  passed  away  largely ;  has  it  progressed  slowly ;  does  slight  pressure  on 
the  pulpal  wall  cause  pain ;  has  the  pulpal  wall  been  broken  through ;  is 
there  growth  of  the  pulp  tissue  out  into  the  cavity?  These  are  the 
things  that  aid  us  in  determining  upon  the  correct  diagnosis. 

Rypertropby  of  the  Pulp. 

In  inflammatory  cases  where  suppuration  does  not  ensue  the  pulp 
oftentimes  seems  to  grow  rather  than  break  down.  There  is  a  continual 
growth  of  new  cells,  just  as  in  reparative  inflammation  in  healthy  tissue. 
These  cells  of  repair  continue  to  divide,  after  forming  new  nuclei  within 
themselves,  until  we  actually  have  a  growth  of  new  tissue  out  into  the 
cavity  of  decay  (see  Fig.  22). 

In  a  cavity  of  this  kind  the  pulp  is  actually  pushed  into  it.  Often- 
times the  odontoblasts  and  fibrils  are  pushed  out  also.  In  other  cases  the 
growth  is  within  the  tissue  itself,  and  not  simoly  the  exposed  point. 
These  cases  are  not  usually  painful,  for  the  reason  that  there  is  a  way  of 
escape  for  the  swollen  enlarged  tissue. 


56 


Fig.  23. 
A,   diagram    of   lower    molar   with    cavity   at    a   completely  filled   with   hypertrophied  pulp  tissue 
grown   out    through   opening    into   pulp    chamber    at    b;   B,    showing    granulation    tissue    of    hyper- 
trophied portion;    a,    epithelial   cells  with   papilla;    h,  epithelial   cells  without  papilla.     (Black.) 


1>ow  to  study  1>yperemia  ana  Tnflammation  Tn  tooth  Pulp. 

A  word  as  to  how  we  study  the  conditions  of  hyperemia  and  inflam- 
mation in  the  dental  pulp.  I  will  give  you  a  method  which  has  been 
quite  universally  adopted  of  late,  a  method  suggested  by  Dr.  Black.  That 
is  first  to  get  the  patients  wliile  they  are  sufifering  from  the  paroxysms 
of  pain.  If  the  paroxysm  has  passed  over,  wait  for  another  attack,  or 
excite  it  by  thermal  changes ;  then  while  the  pain  is  at  its  height  extract 
the  tooth  and  immediately  drop  it  into  Miller's  fixing  fluid. 

The  object  is  to  capture  the  condition,  as  Dr,  Black  states,  and  harden 
the  tissues  so  it  can  be  handled  without  in  any  way  disturbing  the  con- 
tents of  the  vessels.  Then  it  is  broken  open  in  a  vise  and  the  whole  thing 
dropped  into  Miller's  fluid  again,  and  while  under  this  fluid  the  pulp  is 
separated  out  and  lifted  out  of  its  bed.  Oftentimes  you  will  lift  the  pulp 
with  the  odontoblasts'  and  the  fibrils  attached  to  it,  some  of  them.  Now 
leave  in  Miller's  fluid  for  farther  hardening,  after  which  it  is  dropped 
into  a  solution  of  gum  arable  which  has  been  thickened  by  slow  evapora- 
tion. Of  course  the  object  of  this  is  to  fix  it  so  it  will  be  hard  enough  to 
handle.     After  24  hours  it  is  put  in  wax,  and  after  12  hours  it  is  cut  in 


57 

the  ordinary  manner  of  cutting  specimens,  mounted  and  examined  under 
ihe  -microscope,  with  the  results  that  I  have  given  here. 

Causes. 

There  is  very  httle  that  can  be  said  as  to  the  causes  of  inflammation 
in  the  tooth  pulp  other  than  what  has  been  said  regarding  hyperemia,  to 
which  the  reader  is  referred.  Indeed,  as  has  been  said,  inflammation 
usually  begins  in  hyperemia,  and  the  reader  must  bear  in  mind  the  fact 
that  all  severe  hyperemias  are  liable  to  run  into  inflammation,  and  unless 
steps  are  taken  early  to  prevent  this,  the  vitality  of  the  pulp  will  have  to 
be  sacrificed.  Bear  in  mind  that  inflammation  rapidl}^  follows  pulp  expo- 
sure from  caries  or  accidents  in  excavation ;  but  inflammation  of  the  pulp 
does  not  depend  on  these,  but  the  same  variety  of  causes  that  have  to  do 
with  hyperemia  obtained  as  well. 

The  use  of  corrosive  agents,  shock,  lowered  vitality  of  the  general 
system  have  an  important  bearing  on  inflammation  in  the  tooth  pulp,  the 
same  as  in  other  parts  of  the  system. 

treatment  of  Inflammation  of  tbe  tootb  Pulp. 

Regarding  the  treatment  of  pulp  inflammation  the  same  principles 
that  are  carried  out  regarding  other  inflammations  elsewhere  about  the 
body  must  be  followed  here,  which  relates  to  removing  the  cause  and  in 
putting  the  proper  part  to  rest.  We  must  remember  that  intense  pain 
is  usually  present,  and  it  is  our  business  to  relieve  this  as  quickly  as 
possible. 

If  irritation  through  a  carious  cavity  is  the  cause,  then  that  should 
receive  our  first  attention.  The  method  I  follow  in  this  regard  is  to  care- 
fully break  down  the  overhanging  enamel  and  wash  the  cavity  thoroughly 
with  warm  antiseptic  solution,  after  which  I  apply  the  rubber  dam  and 
dry  the  cavity,  using  dehydrating  agents  and  warm  or  cool  air,  which- 
ever feels  more  comfortable  to  the  patient.  I  next  excavate  the  carious 
dentine,  proceeding  in  such  a  manner  as  to  produce  the  least  possible 
pain ;  this  usually  can  be  accomplished  best  by  removing  the  decay  from 
all  walls  around  the  pulp  first,  leaving  the  pulpal  wall  to  be  removed 
with  one  stroke  of  the  excavator.  In  the  use  of  our  excavators  if  we  cut 
from  the  pulp  rather  than  towards  it,  we  are  less  liable  to  injure  it  and 
to  produce  pain. 

In  making  the  excavation  if  the  pulp  is  exposed  so  as  to  bleed  the 
pain  will  be  relieved  thereby  in  most  cases.  If  exposure  does  not  occur 
in  this  manner  it  is  regarded  as  good  practice  to  open  the  pulp,  provided 
this  can  be  accomplished  without  causing  too  much  suffering.  Often- 
times this  can  be  accomplished  with  the  aid  of  warm  carbolic  acid,  cocain 
or  other  local  anesthetics,  and  some  operators  administer  nitrous  oxide. 


58 

and  remove  the  pulp  immediately.  I  wish  to  emphasize  the  value  of  blood 
letting  whenever  severe  pain  is  present.  The  next  step  is  to  apply  some 
mild  antiseptic  soothing-  agent  and  seal  the  cavity  in  such  a  way  as  not 
to  produce  pressure  on  the  pulp  and  at  the  same  time  preclude  any  possi- 
bility of  the  patient  forcing  the  stopping  down  against  the  pulp  in  the  act 
of  masticating.  The  hot  foot  bath  will  serve  to  attract  the  force  of  the 
circulation  from  the  head  and  thus  relieve  the  pain.  A  little  mustard 
added  to  the  hot  water  will  increase  its  efficacy.  The  administration  of 
saline  cathartic  is  commended  in  severe  cases,  especially  where  there  is 
some  tendency  to  pus  formation.  For  the  purpose  of  relieving  pain  it 
is  occasionally  necessary  to  resort  to  the  use  of  some  of  the  narcotics  and 
heart  depressants.  It  is  not  considered  good  practice  to  attempt  pulp  de- 
vitalization in  these  painful  cases  until  the  pain  has  been  relieved  and  the 
patient  m.ade  comfortable  for  at  least  forty-eight  hours.  This  fact  will 
be  alluded  to  under  pulp  devitalization. 


CHAPTER  VII. 


PuliJ  Capping. 

History.     Favorable  and  Unfavorable  Cases.     ^Methods   of   Pulp  Capping. 


history. 


In  looking  over  the  literature  I  find  that  men  have  long  been  cap- 
ping pulps.  I  find  records  of  pulp  capping  as  far  back  as  1850.  In  that 
early  day  men  knew  nothing  scarcely  of  how  to  treat  diseased  pulps  and 
fill  root-canals,  so  palliative  measures  were  used  until  the  aching  tooth 
was  quiet :  then  fillings  were  made,  sometimes  without  even  linmg  the 
cavitv.  ]\Iost  of  their  cases  died  and  suppurated.  Then  they  either  bored 
a  hole  underneath  the  gum  margin  or  extracted  the  tooth.  A  little  later 
than  this,  in  about  1858.  men  began  to  cap  pulps  with  oxychloride  of  zinc, 
and  from  that  early  time  until  this  the  subject  has  engaged  the  attention 
of  many  experimenters.  Almost  all  sorts  of  materials  have  been  used — 
lead,  tin.  asbestos,  varnishes,  gutta-percha,  oxyphosphate.  all  of  these 
have  had  their  adherents.  In  1888  I  remember  hearing  this  subject  dis- 
cussed before  the  American  and  Southern  Dental  Societies,  which  met 
in  joint  session  in  Louisville.  There  seemed  to  be  a  very  unanimous  opin- 
ion then  that  failures  were  had  more  frequently  than  success.  I  remem- 
ber well  the  remarks  of  Dr.  Storey,  of  Dallas,  Tex.  He  stated  that  he 
had  taken  up  the  then  prevalent  fad  of  capping  pulps  and  had  used  all 
the  accepted  materials,  and  in  the  next  few  years  had  more  business 
than  he  could  possibly  attend  to.  and  most  of  it  was  caring  for  putrescent 
pulps  and  abscesses  in  teeth  whose  pulps  he  had  previously  successfully 
capped.  AMiile  this  has  not  been  my  experience,  yet  I  have  capped  many 
pulps,  a  majoritv  of  Avhich  have  been  failures.  I  have  tried  to  study  out 
the  causes  of  these  failures,  with  the  result  that  I  now  cap  comparatively 
few  exposed  pulps,  and  those  under  the  most  favorable  circumstances, 
which  circumstances  I  have  already  stated  to  you.  Many  men  report  suc- 
cessful cases  of  capping  who  have  not  the  opportunity  of  following  them 
up.  Cases  leave  us  when  we  are  unsuccessful  and  we  never  learn  of  our 
failures.  I  know  I  am  called  upon  frequently  to  treat  cases  where  pulps 
were  previously  capped  by  others.  These  cases  sometim.es  go  on  for 
vears  and  give  no  trouble.  I  have  had  cases  under  direct  observation 
for  three  and  four  years ;  I  was  able  to  know  that  the  pulp  was  alive  dur- 
ing that  time,  and  then  all  at  once,  without  warning,  trouble  begins. 

There  are  men  who  claim,  to  be  able  to  remove  a  portion  of  the  pulp 


6o^ 

surgically,  as  it  were,  and  cap  the  remaining  portion.  They  sometimes 
remove  the  bulbous  portion  in  the  pulp-chamber  and  the  contents  of  one 
of  the  root  canals  in  a  molar  and  cap  the  remainder.  You  will  find  as 
you  read  the  literature  on  the  subject  that  men  have  actually  practiced 
this  sort  of  thing,  not  only  practiced  it,  but  advocated  it  for  years.  I 
must  say  that  it  will  require  much  stronger  evidence  than  I  have  seen  to 
convince  me  that  the  remaining  portion  lives  in  a  healthy  state  any 
length  of  tijne. 

Taporable  and  Unfavorable  €a$<$. 

When  to  cap  a  pulp  and  when  to  destroy  it  are  questions  which  can 
only  be  decided  after  considering  a  great  many  things,  among  which  are 
the  following : 

First — The  exposure.  Is  there  an  actual  exposure  ?  Has  the  carious 
process  exposed  the  pulp?  Is  there  only  a  slight  exposure  in  the  horn 
of  the  pulp?  Was  it  exposed  in  removing  the  decalcified  dentine?  Was 
it  exposed  by  an  accidental  slip  of  the  instrument?  These  conditions 
can  all  readily  be  observed  after  the  tooth  has  been  cleaned,  washed  and 
dried.  If  there  is  any  doubt,  slight  pressure  on  the  pulpal  wall  with  a 
small  ball  of  cotton  or  round  burnisher,  when,  if  exposed,  pain  will  be 
felt  by  the  patient. 

Second — Has  the  pulp  been  infected?  This  is  usually  the  case  if 
caries  has  penetrated  directly  to  it,  or  if  exposed  by  accident,  which 
sometimes  unavoidably  occurs.  Infection  is  very  likely  to  result  if  ex- 
posed to  the  air  for  any  length  of  time. 

Third — What  is  the  history  of  the  case?  Has  the  pulp  caused  pain 
to  any  extent  ?  Has  it  been  hyperemic  or  congested  at  any  time  ?  These 
are  all  unfavorable  indications,  and  failure  will  surely  result  from  at- 
tempting to  cap  such  pulp,  no  matter  what  method  is  followed. 

Fourth — Has  the  pulp  been  actually  injured?     How? 

Fifth — What  is  the  history  of  previous  cappings  in  the  same  mouth  ? 
Had  the  patient  the  unpleasant  experience  of  having  pulps  capped  under 
similar  conditions  and  then  die  with  all  the  pain  of  an  acute  alveolar 
abscess  resulting  therefrom  ? 

Sixth — Has  the  tooth  fully  developed?  It  is  so  important  to  pre- 
serve the  vitality  of  the  pulp  until  the  tooth  is  thoroughly  formed  that  I 
sometimes  take  a  chance  even  when  certain  conditions  are  inclined  to  be 
unfavorable,  for  to  destroy  a  pulp  in  a  partially  formed  root  means  the 
loss  of  that  tooth  sooner  or  later. 

Seventh — What  is  the  general  health  of  the  patient?  I  have  poor 
success  in  capping  pulps  for  anemic  individuals,  those  suffering  from 
poor  elimination,  or  those  of  nervous,  hysterical  makeup. 


6i 

Eighth — Is  the  tooth  situated  in  the  anterior  part  of  the  mouth, 
where  the  natural  translucency  of  the  tooth  is  very  desirable  ? 

Ninth — Is  is  not  desirable  to  cap  pulps  that  require  much  medication 
to  restore  them  to  comfort  ? 

These  are  some  of  the  questions  which  must  pass  through  your  mind 
before  you  should  decide  either  for  or  against  capping.  There  is  still 
another  important  point  to  consider  in  this  matter,  and  that  is  with  ref- 
erence to  the  personality  of  the  patient.  Is  she  one  of  those  who  will  un- 
reasonably blame  you  if  failure  results  ?  There  are  a  few  people  who  feel 
that  when  they  have  a  cavity  filled  that  should  for  all  time  end  their 
trouble  with  that  tooth,  and  if  the  pulp  should  die  in  such  a  tooth  they 
would  condemn  the  dentist  both  loud  and  long  as  an  impostor. 

methods  of  Pulp  Capping. 

In  preparing  pulps  for  capping  it  is  desirable  to  free  the  cavity  from 
all  poisonous  material  and  cut  to  sound  dentine  upon  which  to  rest  the 
periphery  of  the  capping.  If  this  does  not  actually  uncover  the  pulp  so 
much  the  better,  but  in  any  event  it  is  important  that  there  should  be  no 
space  between  the  cap  and  the  pulp.  It  should  lie  down  on  the  pulpal 
wall,  or  in  case  of  an  actual  exposure  down  on  the  pulp  itself  with  no 
space  for  air,  secretions  or  excretions  from  the  pulp,  and  yet  this  must  be 
done  without  the  slightest  pressure  upon  that  organ. 

Materials. — A  great  variety  of  substances  have  been  suggested  as 
pulp  cappings,  many  of  which  have  been  tried  and  discarded.  Oxychlo- 
ride  of  zinc  mixed  into  a  thin  paste,  dropped  on  one  of  the  walls  of  the 
cavity  and  coaxed  over  the  pulp  in  such  a  manner  as  to  exclude  the  air 
has  been  used  by  some  for  many  years.  Others  cut  a  piece  of  white 
linen  paper  just  large  enough  to  cover  the  pulpal  wall  and  put  the  zinc 
cement  on  this  and  carry  one  end  to  place,  then  gently  press  from  this 
towards  the  opposite  end,  forcing  some  cement  ahead  of  your  pressure 
and  out  around  the  periphery.  Many  advocate  zinc  oxyphosphate  cement 
used  instead  of  the  oxychloride,  and  others  the  oxysulphate  of  zinc. 
Zinc  oxide  cement  powder  mixed  with  oil  of  cloves  or  other  similar 
oil  has  many  advocates.  Some  practitioners  use  iodoform  lo  per  cent 
with  the  cement  powder,  then  mix  either  with  oil  of  cloves  or  the  cement 
liquid ;  in  all  of  these  the  method  of  capping  is  the  same.  Instead  of  the 
white  linen  matrix  many  use  gutta-percha  disks  cut  small  enough  and 
depressed  slightly  in  the  center  of  the  surface  to  be  placed  next  to  the 
pulp ;  on  this  depressed  surface  is  placed  some  one  of  the  above  mixtures 
and  carried  to  place,  as  before  described.  Small  metallic  concave  disks 
have  been  made  for  this  purpose,  and  have  the  advantage  of  being  more 
convenient  of  application.     Solution  of  gutta-percha  in  chloroform  and 


62 

some  of  the  balsam  varnishes  in  alcohol,  to  which  may  be  added  oil  of 
cloves,  iodoform  or  some  other  agent,  have  been  suggested.  These  solu- 
tions are  used  on  the  little  disks  in  the  same  manner  as  the  cement  mix- 
tures. A  word  of  caution  needs  to  be  given  regarding  the  use  of  zinc 
oxide ;  many  specimens  have  arsenic  present  in  them  which  should  be 
avoided. 

Insist  on  having  a  pure  oxide.  Dr.  A.  E.  Royce  has  recently  sug- 
gested incorporating  5  per  cent  hydronaphthol  in  the  cement  powder, 
and  from  this  make  a  mix,  using  the  same  means  of  applying  that  I  have 
already  suggested.  I  have  had  very  satisfactory  results  from  this  mix- 
ture, that  is,  if  an  opinion  formed  after  two  years  of  frequent  using  is  of 
value. 

It  is  the  usual  practice  to  complete  the  filling  in  all  these  cases  either 
with  gutta-percha  or  oxyphosphate  cement — especially  a  layer  of  cement 
over  the  capping.  If  the  tooth  remains  normal  for  a  period  of  six 
months  it  is  usually  considered  proper  to  place  the  permanent  filling. 

I  think  it  wise  to  add  this  further  word — all  modern  pathologists 
regard  vital  pulps  that  are  normal  to  be  of  great  advantage  to  teeth  as 
regards  their  resitance  to  decay,  their  color  and  general  comfort  to  the 
patient. 

In  concluding  this  subject  I  wish  to  say  that  when  you  have  used 
your  best  judgment  both  as  to  the  case,  the  materials,  and  the  method  of 
doing  the  operation,  sometimes  failures  will  result.  Some  cases  will  go 
for  years  without  the  least  discomfort  to  the  patient,  and  all  at  once 
take  on  violent  inflammation  ;  others  die  and  give  no  trouble,  and  still 
others  start  up  trouble  immediately  after  the  capping  is  placed,  which  in- 
creases until  death  of  the  organ  results  either  of  itself  or  at  the  hands  of 
the  operator — so  that  we  must  not  be  too  sure  of  success,  and  yet  this 
operation  is  done  successfully  often,  and  under  favorable  conditions  in  a 
great  majority  of  cases. 


CHAPTER  VIII. 

Pulp  Devitalization. 

Methods.     Preparation  of  Cavity  to  Receive  Arsenic. 


Devitalization  of  pulps  is  a  subject  of  increasing'interest.  Many  teeth 
come  under  our  care  that  have  passed  beyond  our  ability  to  save  with  pulp 
alive,  and  have  them  remain  so  for  any  length  of  time.  We  devitalize 
pulps  for  the  following  reasons : 

First.  Inflamed,  aching  pulps  that  have  gone  beyond  conditions 
favorable  for  capping. 

Second.  Cavity  may  be  so  shaped  or  caries  progressed  so  far  as  to 
make  permanent  filling  impossible  without  anchoring  in  the  pulp-chamber. 

Third.  A  crown  may  be  necessary,  either  to  restore  a  broken  down 
tooth  or  as  an  abtitment  for  a  bridge.  In  these  cases  it  is  seldom  possible 
to  properly  prepare  for  a  crown  without  removing  the  pulp,  on  account  of 
its  sensitiveness  and  the  danger  of  approaching  too  near  the  horn  of  the 
pulp ;  also  danger  of  exposing  the  entire  dentin  and  fibrils  to  severe  irri- 
tation of  large  amount  of  zinc  cement,  thermal  changes,  etc.,  etc.  I  am 
not  one  of  those  who  claim  that  it  is  impossible  to  occasionally  fit  a  crown 
for  an  abutment  of  a  bridge  without  devitalizing  the  tooth ;  I  believe 
there  are  many  teeth  where  it  is  possible  to  do  that,  but  in  the  great 
majority  of  cases  it  is  not  possible.  It  is  claimed  by  some  that  when  teeth 
are  ground  in  this  manner  for  the  adjustment  of  crowns  and  bridges,  and 
the  pulps  left  alive,  that  the  action  of  the  arsenic  contained  in  the  cement 
will  eventually  destroy  the  pulp.  I  have  never  been  able  to  get  interested 
in  the  theory  of  pulps  dying  under  the  arsenic  contained  in  the  cement. 
I  never  felt  that  that  was  sufficiently  proven  to  be  taken  as  a  fact. 

Fourth.  We  devitalize  pulps  in  teeth  in  advanced  stages  of  pyorrhea 
alveolaris. 

Fifth.  We  devitalize  pulps  where  the  patient  is  suffering  from 
calcific  deposits  within  the  pulp  itself.  Oftentimes,  as  I  stated  before, 
this  occurs  in  teeth  that  are  perfectly  sound,  so  far  as  we  can  tell,  and  our 
only  method  of  getting  permanent  relief  for  the  patient  is  to  devitalize 
and  remove  the  pulp. 

Before  attempting  to  devitalize  we  should  first  restore  the  tissue  to  a 
normal  condition,  so  far  as  possible.  Inflamed,  aching  pulps  need  some 
palliative  treatment  first,  either  by  actually  exposing  the  pulp  and  letting 
out  some  of  the  blood,  or  in  case  the  pulp  is  very  hypertrophied,  with 


64 

the  use  of  a  little  carbolic  acid  and  cocain  we  cut  off  the  hypertrophied 
portion  before  attempting-  to  apply  the  devitalizing  paste.  For  the  pallia- 
tive treatment  we  usually  use  oil  of  cloves,  carbolic  acid,  creosote,  chloro- 
form and  some  of  the  oils,  cocain  and  warm  oil  of  cloves,  morphia,  lauda- 
num, alcohol  and  the  essential  oils  ;  any  of  these  sealed  in  widiout  pressure, 
and  left  for  a  day  or  two  until  the  pain  has  subsided.  The  reasons  for 
doing  this  are  two.  First,  an  inflamed  pulp  is  very  resistant  to  the  ab- 
sorption of  devitalizing  agents.  That  is  an  experience  that  I  am  sure 
all  have  had  who  have  attempted  to  devitalize  aching  pulps.  Second,  our 
devitalizing  agent  acts  as  a  further  irritant  and  sometimes  causes  intense 
suffering  needlessly.  In  cases  where  there  is  only  slight  sensitiveness  and 
the  pulp  has  begun  to  suppurate  in  its  horn,  I  have  had  best  results  by 
letting  out  the  pus,  washing  out  freely  with  warm  antiseptic  solutions, 
using  then  a  good  antiseptic  or  germicide  to  do  away  with  the  suppura- 
tion, and  then  proceed  to  devitalize  and  remove  the  living  portion. 

Care  must  be  taken  not  to  mistake  pressure  on  the  pulp-chamber 
content  for  irritation  to  the  fibrils.  That  is  a  mistake  that  is  made  very 
frequently.  When  we  come  to  excavating  close  to  the  pulp  we  will  find 
that  we  give  pain  oftentimes  when  really  the  pulp  itself  is  practically 
jdead.  The  reason  for  this  pain  is  that  the  chamber  is  filled,  literally  filled 
-full  of  material,  and  the  slightest  pressure  upon  it  produces  irritation 
beyond  the  apex.  You  will  often  open  up  teeth,  even  after  you  have 
applied  your  devitalizing  paste,  that  seem  sensitive  upon  excavation,  when 
with  a  little  care  you  can  succeed  in  exposing  a  little  corner  of  the  pulp, 
and  after  you  have  done  that  you  can  proceed  to  open  it  completely  and 
remove  it  without  any  pain  whatever. 

The  object  in  devitalizing  pulps  is,  of  course,  that  they  may  be 
removed  painlessly.  I  might  say  that  dentists  oftentimes  really  forget 
the  object  of  devitalizing  pulps,  and  proceed  to  half  devitalize  and  remove 
them  with  as  much  pain  as  if  they  hadn't  attempted  to  devitalize  at  all, 

methods. 

Orangewood  stick.  The  oldest  method  so  far  as  I  can  learn  that 
is  practiced  to  any  extent  at  the  present  time  is  called  knocking  the  pulp 
out.  For  this  method  the  pulp-chamber  must  be  thoroughly  opened, 
the  entire  pulpal  wall  removed,  a  piece  of  orange  or  rose  wood  is  whittled 
quite  like  a  sharpened  lead  pencil  approximating  the  size  and  shape  of  the 
root  canal,  this  is  dipped  in  carbolic  acid,  and  held  in  direct  line  with  the 
pulp  the  point  touching  it,  the  stick  is  then  struck  a  quick  blow  with  the 
mallet.  If  everything  works  weli,  the  pulp  can  be  removed  c[uickly  and  in 
some  instances  painlessly,  but  many  unlocked  for  things  may  happen 
such  as  breaking  the  stick,  driving  it  through  the  apex,  or  failure  because 


65 

of  the  irregular  shape  of  the  canal  Then  the  pain  caused  in  so  thoroughly 
opening  the  chamber  is  frequently  severe.  Altogether  I  regard  this  as  a 
relic  of  barbarism,  which  should  be  forgotten,  and  yet  some  good  prac- 
titioners use  this  method  occasionally.  My  only  excuse  for  presenting  the 
subject  is  its  antiquity. 

Carbolic  acid  method.  Carbolic  acid  has  been  used  for  many  years 
as  a  corrosive  agent  to  destroy  pulps  little  by  little,  requiring  frequent 
applications,  and  many  days'  time ;  but  more  recently  it  has  been  used  by 
hyperdermic  injection  directly  into  the  pulp  tissue  using  a  very  fine  needle 
carried  up  along  the  wall  of  the  chamber  for  nearly  half  the  length  of  the 
canal,  then  forcing  a  drop  or  so  of  the  melted  crystals  into  the  pulp.  In 
a  few  moments  it  can  be  removed  quite  painlessly,  the  pain  of  opening 
the  chamber  and  introducing  the  needle  are  often  as  great  as  to  remove  the 
pulp  forcibly  without  it. 

Cocain.  Many  methods  of  using  cocain  for  the  purpose  of  anesthetiz- 
ing the  pulp  have  been  tried,  only  two  of  which  seem  to  be  used  at  the 
present  time — viz.,  the  cataphoric  electric  apparatus,  and  pressure  method 
used  in  exactly  the  same  manner  as  has  alread\'  been  suggested  in  Chapter 
II.  for  obtunding  sensitive  dentine,  with  addition' of  forcing  the  cocain 
so  thoroughly  into  the  pulp  tissue  that  all  sensation  is  lost.  The  objec- 
tions to  cocain  extirpation  are  these : 

First.  The  danger  of  forcing  poison  of  some  nature  through  the  apex 
and  injuring  the  tissue  beyond. 

Second.  The  injury  to  the  tissues  in  the  apical  space  caused  by  tear- 
ing the  pulp  away. 

Third.  The  hemorrhage  that  usually  follows. 

Fourth.  The  soreness  attending  the  absorption  of  the  blood  clot  left 
in  the  apical  space. 

Fifth.  The  danger  of  leaving  a  small  fragment  of  pulp  tissue. 

The  advantages  are  these : 

First.     The  time  saved ;  operation  can  be  completed  in  one  sitting. 

Second.     Less  liability  of  tooth  discoloration. 

Third.   In  many  cases  less  painful  than  the  arsenic  method. 

Cocain  method.  The  pressure  method  seems  to  have  entirely  dis- 
placed the  cataphoric  electrolysis.  The  first  essential  in  the  use  of  the 
pressure  method  is  a  clean  cavity,  so  shaped  that  cocain  solution  can  be 
confined  under  pressure — this  will  often  necessitate  the  building  of  a 
third  wall,  to  m.ake  the  cavity  nearly  cup  shaped.  After  the  pulpal  wal! 
is  obtunded  it  should  be  thoroughly  removed  before  continuing  pressure  to 
fully  anesthetize  the  pulp  in  order  to  avoid  forcing  micro-organic  poisons 
into  the  tissues  beyond ;  then  the  pumping  can  be  done  with  some  such 
instrument  as  is  represented  in  Fig.  23A,  or  a  piece  of  soft  rubber  a  little 


66 


III 


larger  than  the  cavity,  and  forcing  the  cocain  solutions  into  the  tubuh 
by  pressing  this  against  the  cotton  carrying  the  solution,  with  a  sort  of 

pumping  motion,  gently  at  first  and  then  in- 
creasing gradually.  This  pumping  should 
continue  until  all  signs  of  sensitiveness  are 
quite  gone.  This  pumping  should  begin 
gently  then  with  increasing  force  until  consid- 
erable force  is  exerted.  A  smooth,  fine  broach 
should  be  passed  along  the  chamber  wall,  and 
if  slight  sensitiveness  is  found  the  cocain 
should  again  be  pumped — until  the  smooth 
broach  will  pass  to  the  apex  without  causing 
pain  which  should  require  not  more  than  five 
minutes.  A  barbed  piano  wire  broach  which 
has  been  selected  for  the  case,  tested  and 
sterilized  should  be  carried  well  into  the  canal, 
turned  half  a  revolution  and  withdrawn,  when 
in  most  cases  the  pulp  will  come  away  entirely. 
Care  should  be  exercised  not  to  cut  or  tear  the 
pulp  tissue,  roughly  forcing  in  the  broach,  or 
turning  it  too  much  and  cutting  the  tissue  into 
little  pieces.  When  the  pulp  is  torn  in  this 
manner  it  is  almost  impossible  to  remove  all 
the  shreds  before  sensitiveness  returns,  and  to 
remove  these  shreds  is  a  task  that  sometimes 
puzzles  the  most  skilful ;  in  my  hands  the  most 
successful  method  of  doing  so  is  by  entangling 
I'i^H  them  in  cotton  loosely  wound  on  a  broach  and 

dipped  in  95  per  cent  carbolic  acid. 

For  the  purpose  of  controlling  and  prevent- 
ing hemorrhage  a  number  of  hemostatic  agents 
have  been  suggested  but  the  use  of  i-iooo 
solution  of  adrenalin  chloride  as  a  vehicle  for 
dissolving  the  cocain  crystals  seems  to  be  most 
often  used,  and  in  cases  where  there  is  no 
hyperemia  of  the  tissue  in  the  apical  space, 
seems  to  meet  every  requirement.  We  should 
bear  in  mind  that  most  cases  calling  for  pulp 
removal  are  those  that  have  recently  been  in 
a  state  of  inflammation,  and  it  is  almost  cer- 
tain that  a  hyperemic  condition  exists  beyond 
Tuiier's  cataphoretic  instrument      the  apcx,  in  which  case  a  reasonable  amount  of 


67 

bleeding  will  be  helpful  and  should  be  encouraged.  So  far  as  using 
blood  coagulating  or  clotting  agents  is  concerned  for  the  purpose 
■oi  stopping  the  hemorrhage  after  pulp  is  removed,  I  wish  to  ask 
what  is  to  become  of  this  clot  which  to  be  of  any  value  must  be  beyond 
the  root  canal  foramen  ?  Clearly  it  must  be  absorbed  or  organized  and  is 
this  not  a  source  of  danger?  I  think  it  best  to  wait  a  few  minutes  on 
nature,  and  let  her  stop  the  bleeding  by  closing  the  lumen  in  the  broken 
vessels.  The  next  step  is  to  remove  the  blood  mechanically,  with  aseptic 
■cotton  and  proper  broaches,  and  finally  with  alcohol.  Dr.  J.  P.  Buckley 
calls  attention  to  the  error  of  using  hydrogen  dioxide  for  this  purpose ; 
it  tends  to  discolor  the  tooth  substance.  After  thorough  dehydrating  some 
mild  soothing  agent  should  be  sealed  in  for  a  few  days,  to  allow  nature 
to  heal  and  restore  to  normal  the  tissues  about  the  root  apex. 

For  this  purpose  I  use  a  mixture  of  eucalj'ptol,  oil  of  cloves  and 
trikresol,  placing  the  smallest  quantity  possible  on  antiseptic  cotton 
carried  well  into  the  canal.  The  reasons  for  not  filling  the  canal  imme- 
diately upon  the  pulp  removal,  are  two ;  the  tissues  beyond  are  more  or 
less  anesthetized  and  consequently  will  not  respond  in  such  a  way  as  to  tell 
you  when  apex  is  just  closed,  and  no  filling  material  forced  beyond  and 
second,  there  is  some  liability  of  leaving  a  tiny  shred  of  pulp  tissue  at  the 
apex,  which  will  not  only  prevent  thorough  filling,  but  will  afterwards 
cause  considerable  pain  when  the  anesthesia  has  passed. 

If  we  will  keep  all  these  suggestions  in  mind,  I  have  no  doubt  we  will 
find  the  removal  of  pulps  by  this  method  very  satisfactory  in  most  cases, 
and  perhaps  the  most  satisfactory  of  all  methods,  all  things  considered, 
for  all  single  rooted  teeth  in  the  mouths  of  the  average  patient,  but  in 
three  rooted  teeth,  especially  where  some  of  the  canals  are  very  small,  and 
in  the  mouths  of  very  nervous  people,  the  arsenic  is  preferable. 

Arsenic  method.  The  standard  method,  the  one  most  frequently 
used,  and  of  most  general  application  is  the  arsenic  method.  Arsenic  acts 
by  first  exciting  the  sensory  nerves  and  then  paralyzing  them.  It  always 
arouses  a  degree  of  inflammation  somewhat  dependent  upon  the  amount 
used  so  that  it  is  advisable  to  use  the  least  possible  quantity  to  accom- 
plish the  desired  result.  While  sensation  is  somewhat  paralyzed  a  few 
hours  after  the  application  of  arsenic,  yet  the  tissue  is  not  dead,  or  even 
senseless  for  several  hours  after  application.  Arsenic  causes  death  by 
its  irritant  corrosive  action  ;  death  by  infarction  in  the  apical  portion  is  a 
result  of  the  inflammation  caused.  Inflammation  may  be  so  severe  as  to 
prevent  the  ready  absorption  of  the  arsenic  and  hence  death  will  be  very 
slow  in  such  cases,  and  usually  attended  with  considerable  pain.  This 
-emphasizes  the  folly  of  attempting  this  method  where  pulp  is  in  an 
inflamed  condition.     If  the  pulp  is  quiet  and  small  quantity  used  in  con- 


68 

junction  with  soothing  agents  the  desired  resuh  can  be  attained  without 
pain,  indeed,  in  my  own  hands  it  is  rare  indeed  tliat  I  iiave  trouble  of  this 
kind.  The  preparation  I  use  is  made  as  follows :  Arsenious  acid  and 
finely  powdered  cocain  hydrochlorate  are  taken  in  equal  quantity  and 
thoroughly  rubbed  together,  after  which  sufficient  oil  of  cloves  is  added 
to  make  a  thin  cream ;  to  this  mixture  I  add  one-half  millimeter  squares 
of  white  hard  blotting  paper  until  the  cream  is  absorbed.  In  a  few  hours 
these  will  dry  sufificiently  to  put  in  a  jar  and  not  stick  together. 

The  tiny  squares  can  be  carried  with  the  pliers  and  does  away  with 
all  danger  of  getting  arsenic  anywhere  but  at  the  point  desired.  The 
brown  color  which  they  soon  assume  is  an  added  advantage.  It  is 
advisable  to  place  arsenic  preparation  directly  over  an  exposure  of  the 
pulp,  but  this  is  not  absolutely  necessary  for  it  will  cause  death  of  the 
pulp  when  applied  just  beneath  the  enamel  if  long  enough  time  is 
given — but  the  danger  lies  in  tooth  discoloration  from  solution  of  liemo- 
globin  in  the  blood — and  yet  this  danger  is  not  so  great  as  miake  exposure 
an  absolute  necessity,  when  that  can  only  be  accomplished  at  the  cost  of 
a  great  deal  of  pain.  As  stated  before  the  object  of  devitalization  is  that 
the  pulp  may  be  removed  painlessly  and  if  we  cause  much  pain  in 
applying  the  remedy  we  have  not  accomplished  the  thing  desired.  In 
most  cases  calling  for  this  treatment  the  pulp  is  already  exposed  by  caries, 
and  is  only  covered  by  decayed  dentine  which  can  easily  be  removed  by 
following  the  method  in  excavating  already  suggested.  After  the  prep- 
aration is  placed  it  should  be  covered  with  some  material  that  will  make 
a  perfect  seal  and  yet  not  press  on  the  tissue. 

Preparation  of  €auity  to  Receive  Jlrsenic, 

A  very  important  point  to  consider  is  the  proper  preparation  of  the 
cavity — it  must  have  sound  walls  and  margins,  particularly  at  the 
gingival — and  so  shaped  that  the  sealing  wall  not  be  driven  out  or  down  in 
the  act  of  mastication. 

In  very  many  proximal  cavities  the  gingival  wall  is  under  the  gum 
gingivus  and  indeed  that  tissue  is  very  often  grown  into  the  cavity,  which 
requires  special  care  in  removing  'or  by  wedging  back.  In  all  cases  the 
rubber  dam  should  be  applied  and  the  field  of  operation  made  clean 
surgically.  Then  a  properly  fitting  matrix  can  be  placed,  and  a  fourth 
wall  built  of  cement  or  in  favorable  cases  gutta-percha,  never  temporary 
stopping,  may  be  used ;  this  should  be  done  before  the  arsenic  is  applied 
and  allowed  to  harden,  when  the  application  can  be  made  and  sealed  with- 
out danger  of  either  pressing  on  the  pulp  or  forcing  the  arsenic  out  upon 
the  gum.  The  tendency  in  the  use  of  arsenic  is  not  to  leave  it  in  contact 
with  the  pulp  long  enough.    I  think  36  or  48  hours  is  short  enough  even  itt 


69 

the  most  favorable  cases,  and  yet  if  a  very  large  quantity  is  used  there  is 
some  danger  of  it  being  carried  beyond  the  apex,  especially  in  young  teeth 
with  large  foramen,  which  means  the  ultimate  loss  of  that  tooth.  After 
arsenic  is  removed  it  is  best  practice  not  to  attempt  removal  of  pulp,  but 
to  seal  in  tannic  acid  to  harden  the  tissue  or  sodium  hydroxid  to  partially 
saponify  it.  The  practice  of  applying  dialyzed  iron  to  the  pulp  after  ar- 
senic is  removed  is  both  useless  and  dangerous,  liable  to  cause  serious 
discoloration  of  the  tooth. 

Either  of  the  above  preparations  should  be  left  sealed  in  for  at  least 
four  days  and  ten  is  better.  Before  applying  these,  however,  the  pulp 
should  be  completely  exposed,  all  decay  removed  and  tested  with  a  smooth 
broach.  Alany  practitioners  believe  it  best  to  remove  the  pulp  immediately 
on  the  removal  of  the  arsenic,  and  in  many  cases  for  lack  of  time  and 
other  special  reasons  this  may  be  necessary.  If,  on  the  other  hand,  these 
other  agents  are  used  and  allowed  to  remain  until  the  pulp  has  been 
thrown  off  from  the  tissues  beyond  the  apex,  root  canal  cleaning  is  greatly 
simplified ;  especially  do  I  like  the  use  of  solution  of  sodium  hydroxid.  I 
have  used  this  preparation  for  several  years,  and  in  all  cases  where  the 
pulp  was  completely  destroyed  by  arsenic  before  applying  it  I  am  able 
to  remove  the  pulp  in  one  piece  leaving  the  canals  clean  and  white,  a  con- 
dition that  is  most  desirable. 

The  cleaning  of  pulp  chambers  will  be  the  subject  of  the  next  chapter, 
but  before  dismissing  this  subject  I  wish  to  refer  to  the  treatment  of 
arsenical  poisoning  of  the  gum  tissue.  When  arsenic  remains  in  contact 
with  the  gum  tissue  for  any  length  of  time  wide  destruction  of  that  tis- 
sue results  which  often  involves  the  periosteum,  pericementum  and  bone. 

By  way  of  emphasis  I  will  cite  a  case  in  point  which  came  to  me  not 
long  ago. 

A  lady  who  had  formerly  been  a  patient  of  mine  went  to  a  neigh- 
boring dentist,  a  young  gentleman  that  she  was  somewhat  interested  in, 
and  anxious  to  aid  in  building  up  a  practice,  and  he  devitalized  the 
pulp  of  a  superior  second  bicuspid  tooth.  She  came  to  me  and  said: 
"Doctor,  I  want  you  to  give  me  a  few  minutes  time."  She  didn't  tell  me 
the  dentist's  name,  and  I  didn't  ask  her,  but  she  said  that  he  had  been  six 
weeks  attempting  to  devitalize  that  pulp,  and  that  the  tooth  had  gotten 
A^ery  sore  and  she  was  alarmed.  Well,  I  put  her  in  the  chair  and  I 
examined  her  case,  and  I  saw  immediately  the  thing  that  had  occurred.  I 
applied  the  rubber  dam  that  she  might  not  know  just  what  I  was  doing. 
T  didn't  want  to  tell  her  because  she  was  very  bitter  against  the  young 
man  by  this  time,  and  I  didn't  want  her  to  know  what  had  occurred  there. 
I  applied  the  rubber  dam  over  the  two  teeth  mesial  and  distal  to  the  space 
where  the  trouble  was,  and  then  with  a  little  manipulation  I  brought  away, 


70 

I  should  say,  a  piece  of  bone  fully  a  half  by  an  eighth  of  an  inch,  or  in 
other  words,  I  brought  away  completely  the  entire  alveolus  between  those 
two  roots  clear  to  the  apex.  I  slipped  it  out  over  the  gum,  and  threw 
it  away,  and  she  didn't  see  it  at  all  and  never  knew  what  had  occurred.  I 
washed  it  out,  and  packed  it  with  antiseptics  and  it  is  filling  in  nicely,  but 
in  all  these  cases  where  the  gum  septum  peridental  membrane  and  alveolar 
border  are  lost  it  is  never  fully  restored  and  always  will  prove  a  source 
of  annoyance  and  require  constant  watching. 

If  you  get  some  arsenic  on  the  gum  accidentally,  what  is  the  thing 
to  do  ?  Swab  it  off  with  dialyzed  iron,  or  what  is  better,  freshly  prepared 
solution  sulphate  of  iron  with  magnesia.  If  at  the  second  operation  you 
find  the  gum  is  destroyed  quite  largely,  what  are  you  going  to  do  ?  You 
may  apply  your  dialyzed  iron,  but  it  won't  do  any  good.  You  simply  have 
to  treat  as  you  would  a  surgical  wound.  Remove  the  dead  material,, 
either  by  actual  operation,  or  by  cauterizing  it  with  carbolic  acid,  nitrate 
of  silver  or  something  of  that  sort,  and  then  keep  the  wound  antiseptic, 
encouraging  it  to  heal  in  every  way  you  can.  I  shall  speak  of  the  man- 
agement of  these  gums  later  in  connection  with  another  subject. 


CHAPTER  IX. 

eieansittg  and  filling  Pulp  (Kbambers. 

The  Pulp  Chamber.     Variations  of  the  Form  of  Pulp  Chambers.    Removing  Pulps. 

Filling  Pulp  Canals. 


the  Pulp  Chamber. 

The  term  pulp  chamber  is  used  to  designate  the  central  cavity  in  the 
dentine  of  the  tooth,  and  is  usually  divided  into  a  crown  part  known  as 
the  pulp  chamber  proper,  and  a  root  portion,  known  as  the  root  canal  or 
root  canals.  An  accurate  knowledge  of  the  anatomy  of  pulp  chambers  is 
of  the  utmost  importance,  and  without  it  many  mistakes  are  made  in 
operating,  both  in  the  preparation  of  cavities  for  fillings  as  well  as  in 
opening  chambers  for  the  purpose  of  removing  pulp,  treatment  and  filling 
canals.  While  pulp  chambers  often  vary  somewhat  from  the  normal, 
yet  an  accurate  knowledge  of  the  normal  will  be  most  helpful  in  dealing 
with  such  abnormalities  as  may  be  met  with  in  daily  practice. 

Teeth  of  different  denominations  have  different  canals,  and  it  mav 
be  said  that  teeth  of  the  same  denomination  often  differ  in  this  regard. 
In  teeth  with  only  one  canal  the  pulp  is  usually  conical,  being  large  in  the 
pulp  chamber  proper  and  gradually  tapering  to  the  apical  foramen,  which 
in  fully  developed  teeth  is  very  small.  The  following  description  and 
illustration  is  adapted  from  Black's  "Dental  Anatomy." 


72 


L4 


A      ^3      ^C       WD       ^^E      TF 


Xi     H         I 


J         ^K 


Fig.  23. 
Longitudinal  section  through  the  center  of  the  teeth,   showing  outline  form  of  pulp   chamber 
and  root  canals.      (Adapted  from  Black.) 


73 

In  the  upper  central  and  lateral  incisors  (Fig.  23,  A,  B,  C,  D)  there 
is  no  distinct  division  of  the  pulp  cavity  into  the  pulp  chamber  and  root 
canal ;  but  there  is  one  straight  canal,  from  the  interior  of  the  body  of 
the  crown  to  the  apex  of  the  root,  of  which  the  crown  portion  is  the 
larger.  In  young  teeth,  this  has  very  distinctly  the  form  of  the  surface  of 
the  tooth  and  root,  except  that  it  is  much  more  slender.  The  largest 
diameter  of  the  cavity  is  about  level  with  the  gingival  line  on  the  labial 
surface.  From  this  point,  the  pulp  chamber,  or  canal,  extends  toward 
the  cutting  edge  of  the  tooth,  about  two-thirds  the  length  of  the  crown, 
sometimes  a  little  more,  often  less,  and  ends  in  a  thin  edge  broad  from 
mesial  to  distal.  From  the  level  of  the  gingival  line  towards  the  apex  of 
the  root  it  tapers  very  gradually  and  regularly  to  a  narrow  canal.  Just 
within  the  apex  of  the  root,  almost  at  the  end,  there  is  usually  a  sudden 
contraction  of  the  diameter  of  the  canal,  lessening  it  from  one-third  to 
one-half. 

The  pulp  chamber  and  root  canal  of  the  upper  cuspid  (Fig.  23,  e,  f) 
is  about  the  same  in  form  as  that  of  the  central  and  lateral  incisors,  ex- 
cept that  the  coronal  extremity  has  the  central  horn  much  extended 
toward  the  apex  of  the  cusp  of  the  tooth,  and  the  mesial  and  lateral 
horns  are  practically  absent.  The  coronal  portion  of  the  pulp  chamber 
of  the  lower  incisors  is  much  flattened  (Fig.  23,  g,  h). 

At  the  level  of  the  gingival  line,  the  long  diameter  is  from  labial  to 
lingual.  The  chamber  extends  towards  the  cutting  edge  of  the  tooth, 
about  two-thirds  the  length  of  the  crown,  and  in  this  extension  its  diam- 
eter is  progressively  diminished  from  labial  to  lingual,  and  extended 
from  mesial  to  distal,  following  the  contour  of  the  surface  of  the  tooth, 
and  ends  in  a  thin  edge.  In  young  teeth  this  has  three  short  projections 
towards  the  mammelons  on  the  cutting  edges  of  the  young,  unworn 
teeth.  The  root  has  usually  a  narrow  slit-like  opening  for  the  greater 
portion  of  its  length,  corresponding  with  the  form  of  the  flattened  roots. 

The  pulp  chamber  and  root  canal  of  the  lower  cuspid  (Fig.  23,  i,  j,  k) 
are  variable  in  size  and  form.  At  the  neck  of  the  tooth  the  cham.ber  is 
usually  irregularly  flattened,  with  the  longer  diameter  from  labial  to 
lingual,  and  the  labial  portion  wider  than  the  lingual.  The  coronal  por- 
tion extends  about  two-thirds  of  the  length  of  the  crown  towards  the 
point  of  the  cusp,  ending  in  a  point,  or  horn,  which  is  often  very  slender. 
The  form  of  the  root  portion  of  the  canal  depends  on  the  form  of  the 
root.  It  is  sometimes  nearly  round  but  more  frequently  it  is  sharply 
flattened  for  the  greater  portion  of  its  length,  becoming  more  rounded 
towards  the  apex. 

Occasionally,  this  canal  is  divided  for  a  part  of  the  length  of  the 
root.     In  upper  first  bicuspids  the  pulp  chamber  and  root  canals  differ 


74 

from  those  of  the  incisors  and  cuspids  by  a  coronal  chamber  distinguished 
sharply  from  the  root  canals  (Fig.  2^,,  1,  m). 

The  chamber  is  centrally  located  in  the  long  axis  of  the  crown  of 
the  tooth,  the  axial  walls  being  about  equal  in  thickness.  The  center  of 
the  pulp  chamber  is  about  level  with  the  gingival  line,  or  a  little  towards 
the  occlusal  surface.  The  occlusal  walls  are  thicker  than  the  axial,  and 
vary  in  thickness  from  one-third  to  two-thirds  of  the  length  of  the  crown 
of  the  tooth.  The  form  of  the  pulp  corresponds  closely  with  the  form 
of  the  tooth.  A  horn  extends  from  the  coronal  portions  towards  the 
apex  of  each  cusp. 

The  root  canals  in  upper  first  bicuspids  that  have  two  roots  pass 
from  the  pulp  chamber  through  the  'tenter  of  each  root  to  the  apex,  and 
are  known  as  the  buccal  and  lingual  root  canals  (Fig.  23,  m).  The  buc- 
cal canal  arises  from  the  extreme  buccal  side  of  the  pulp  chamber,  and 
the  lingual  canal  from  the  extreme  lingual  side,  and  their  course  is 
almost  parallel  with  the  walls  of  these  two  portions  of  the  pulp  chamber.. 

The  pulp  chamber  of  the  upper  second  bicuspid  (Fig.  23  n,  o)is  similar 
to  that  of  the  first,  but.  the  horns  of  the  pulp  are  usually  shorter.  In  this 
tooth  there  is  generally  but  a  single  root  canal,  and  sometimes  there  are 
two  canals  which  end  in  a  common  apical  foramen,  and  sometimes  these 
canals  continue  separately  to  the  apex.  The  pulp  chambers  of  the 
lower  bicuspids  (Fig.  23,  p,  q)  seldom  show  a  marked  distinction  from 
the  root  canals.  There  is,  however,  usually  a  coronal  bulbous  portion 
which  connects  with  the  pulp  canal  proper  by  an  extended  funnel-shaped 
construction.  In  the  lower  first  bicuspid,  the  coronal  extremity  ends  in  a 
horn,  which  -^xtends  towards  the  point  of  the  buccal  cusp.  The  root 
canals  of  ^he  lower  bicuspids  are  usually  large  in  the  first  half,  tapering 
to  a  fine  '"anal  in  the  apical  third  of  their  length.  The  canal  of  the  lower 
first  bicuspid  is  usually  nearly  round,  and  that  of  the  second  is  consid- 
erably flattened — and  in  both  they  are  usually  straight.  Bifurcations  of 
these  canals  are  rare,  but  occur  occasionally. 

The  pulp  chamber  of  the  upper  molars  (Fig.  23,  R,  S)  is  very  dis- 
tinct from  the  pulp  canals,  the  latter  often  leaving  the  former  by  very 
small  openings.  The  form  of  the  pulp  chamber  is  generally  similar  to 
that  of  the  crown  of  the  tooth ;  but  the  horns  in  the  young  tooth  are  often 
quite  slender  as  compared  with  the  cusps,  and  penetrate  far  towards  the 
enamel.  The  length  of  these  diminishes  as  age  advances.  In  teeth  much 
flattened  mesio-distally,  as  often  occurs  in  the  upper  first  molars,  and  espe- 
cially with  the  second,  the  equal  thickness  of  the  axial  walls  is  usually 
maintained  pretty  closely,  so  that  the  flattening  of  the  pulp  chamber 
seems  out  of  proportion  to  the  form  of  the  tooth.  The  floor  of  the  pulp 
chamber  is  rounded  or  arched  in  the  center  (Fig.  24,  A,  f)  and  falls  away 


75 

towards  the  mouths  of  the  canals.     The  latter  is  situated  in  the  portions 
of  the  angles  of  a  triangle. 

The  opening  into  the  lingual  root  is  the  simplest  and  most  direct. 
Generally,  it  begins  in  a  funnel-shaped  opening  inclining  to  the  lingual,. 


Fig.  24. 
A,    the    upper   teeth    cross    section    showing   the   entrance  to  all  the  canals   from  a  to  h  and  a 
to  /;;  D.   the  lower  teeth  cross   section  showing   the  entrance  to  all  the  canals  with  same   letters. 

which  quickly  narrows  to  the  dimensions  of  a  moderately  small  canal,, 
and  continues  to  taper  to  the  apical  foramen.  It  is  usually  straight,  or 
but  slightly  curved. 

The  opening  into  the  mesial  canal  is  under  the  mesio-buccal  cusp, 
close  against  the  mesio-buccal  angle  of  the  pulp  chamber.  To  find  this 
canal  the  point  of  the  broach  should  be  directed  into  the  mesio-buccal 
angle  of  the  pulp  chamber;  and,  while  held  against  the  wall  within  this 
angle,  it  is  slid  towards  the  root,  and  will  rarely  fail  to  glide  into  the 


76 

canal.  The  distal  canal  usually  begins  abruptly  as  a  fine  opening  situated 
at  the  disto-buccal  angle  of  the  floor  of  the  pulp  chamber,  so  that  a 
broach  pressed  into  that  angle  will  easily  glide  into  it.  But  in  some 
instances,  especially  in  the  upper  second  molars,  the  opening  is  in  the 
floor  of  the  pulp  chamber  at  a  little  distance  from  the  immediate  angle 
towards  the  center  of  the  floor,  and  then,  in  positions  which  limit  the  use 
of  the  eye,  it  is  often  difficult  to  find.  In  teeth  much  flattened  at  the 
neck,  the  opening  of  this  canal  may  begin  very  close  to  the  mouth  of  the 
mesial  canal  or  close  against  the  distal  wall  of  the  chamber,  half-way  from 
the  buccal  to  the  lingual  wall  or  anywhere  between  this  point  and  the 
disto-buccal  angle.  This  description  will  do  fairly  well  for  all  upper 
molars. 

The  pulp  chamber  of  the  lower  molars  (Fig.  23,  T,  W)  has  the 
same  general  form  as  the  surface  of  the  crown,  but  is  generally  rather 
more  angular.  The  wall  of  the  chamber  towards  the  occlusal  surface  is 
convex  toward  the  pulp ;  the  horns  extend  from  the  extreme  angles 
towards  the  apex  of  each  cusp.  The  floor  through  the  central  portion  is 
arched  or  convexed  mesio-distally,  and  concave  bucco-lingually  (Fig. 
24-Bf).  The  mesial  wall  of  the  cavity  is  flat  and  longer  than  the  distal. 
The  mesio-buccal  and  mesio-lingual  angles  are  sharp  and  projecting, 
while  the  distal  angles  are  rounded.  The  size  of  the  chamber  varies 
much.  The  root  canals  of  the  lower  molars  proceed  from  the  mesial 
and  distal  portions  of  the  pulp  chamber.  The  mesial  canal,  at  its  mouth, 
is  usually  about  as  broad  from  buccal  to  lingual  as  the  whole  breadth  of 
the  chamber,  including  its  angular  projections.  Either  at  or  a  little  root- 
wise  from  the  floor  of  the  pulp  chamber,  it  is  usually  divided  into  two 
very  small  canals  which  diverge  at  first,  and  approach  each  other  after- 
wards, but  usually  remain  distinct,  each  ending  in  its  own  apical  foramen. 
Occasionally,  how^ever,  they  are  united  in  the  apical  third  of  the  root, 
and  end  in  a  common  apical  foramen.  By  placing  the  point  of  the  broach 
through  the  mesio-buccal  angle  of  the  chamber  and  pushing  it  gently  on, 
it  will  generally  glide  into  the  canal.  The  broach  easily  glides  into  the 
mesio-lingual  canal  by  placing  the  point  in  the  mesio-lingual  angle  of 
the  pulp  chamber  and  sliding  it  towards  the  root.  The  first  inclination 
is  to  the  mesial,  but  occasionally  to  the  lingual,  after  which  it  curves  to  the 
distal  and  buccal.  The  distal  canal  is  approached  by  a  funnel-shaped 
opening,  of  which  the  central  part  of  the  distal  wall  of  the  pulp  cham- 
ber becomes  a  portion.  Its  direction  is  a  little  to  the  distal,  and  generally 
very  nearly  straight  to  the  apex.  It  is  generally  much  larger  than  the 
canals  of  the  mesial  root,  and  is  easily  cleaned  with  the  broach.  If  the 
mouth  is  wide  open  and  the  handle  of  the  broach  brought  against  the 
upper  central  incisors  with  the  point  directed  against  the  posterior  wall 


of  the  pulp  chamber,  it  will  easily  glide  into  the  canal,  and  pass  to  the 
apical  foramen.  Fig.  24  should  be  carefuly  studied ;  it  represents  the 
locations  of  all  the  pulp  chambers. 

Uariations  of  tbc  Torm  cf  Pulp  ebasnbm. 

Many  variations  of  form  occur  in  the  pulp  chambers  and  root  canals. 
The  roots  of  the  teeth  may  be  abnormally  crooked,  and  then  the  canals 
will  be  abnormall}-  crooked.  In  many  instances  the  pulp  chamber  will 
have  in  it  secondary  formations,  called  nodules,  which  may  be  adherent 
to  the  walls  or  block  the  mouths  of  the  canals  and  prevent  a  broach 
gliding  into  them.  These  also  occur,  occasionally,  within  the  canals,  par- 
tially blocking  the  way  of  the  broach.  Sometimes  the  pulp  chamber 
will  be  filled  with  nodular  deposits  so  completely  that  there  seems  to  be 
no  room  for  the  tissue  of  the  pulp.  These  deposits  will  have  to  be 
removed  before  the  root  canals  can  be  reached  and  entered,  after  which 
the  canals  will  generally  be  found  open.  These  deposits  occur  within  the 
pulp  chambers  of  any  of  the  teeth ;  but  they  cause  annoyance  more  fre- 
quently in  the  molars.  Occasionally  lateral  openings  occur  from  the  root 
canals  to  the  surface  of  the  root.  I  have  seen  more  of  these  from  the 
canals  of  the  lower  molars  than  from  those  of  any  other  teeth.  Gener- 
ally they  follow  the  course  of  the  dental  tubules,  and  open  on  the  side  of 
the  root.  They  may  diverge  to  one  side  and  curve  towards  the  apex  of 
the  root.  These  cannot  often  be  detected,  except  in  dissections  of  the 
root,  and  occur  so  rarely  they  may  be  ignored  in  practice.  Sometimes 
the  horn  of  the  pulp  approaches  abnormally  near  the  points  of  the  cusps 
of  some  of  the  teeth,  as  in  the  upper  first  molar.  Then  the  pulp  is 
more  liable  to  exposure  in  excavating  carious  cavities." 

Remooina  Pulps. 

Removing  pulps  is  an  operation  that  is  sometimes  difficult  on  ac- 
count of  the  smallness,  irregularity  and  inaccessibility  of  the  pulp  canals  ; 
particularly  is  this  true  in  the  buccal  canals  of  upper  molar  and  the 
mesial  canals  of  lower  molars — but  in  all  single  rooted  teeth  and  the  large 
straight  canals  the  operation  is  very  easy.  The  first  requisite  for  such 
operations  is  proper  instruments.  A  smooth  fine  piano  wire  broach,  the 
Donaldson  or  Realization  barbed  broach  of  various  sizes,  and  the  Downey 
spiral  broach  of  various  sizes  are  the  instruments  most  needed  (see  Fig. 
25A).  Each  of  these  broaches  should  be  carefully  tested  for  weak  places; 
particularly  is  this  a  necessity  with  all  barbed  broaches,  for  weak  places 
are  very  liable  to  exist.  The  easiest  w^ay  of  making  such  a  test  is  to  take 
the  handle  and  hold  the  point  obliquely  against  the  glass  slab  with 
enough  force  to  spring  it,  at  the  same  time  rotating  it ;  if  a  weak  place 


78 


exists  it  will  fracture  at  that  point,  and  save  you  the  annoyance  of  having 
it  break  in  the  canal.  The  next  important  thing  is  to  secure  the  best  pos- 
sible access  to  the  canals.  I  am  amazed  sometimes  to  see  operators  try- 
ing to  remove  a  pulp  from  a  three  canaled  molar  through  an  opening  in 
the  central  fissure  the  size  of  a  No.  5  round  bur.  The  complete  removal 
of  the  roof  of  the  pulp  chamber  is  the  best  plan,  which  in  most  cases  is 
easily  done  with  an  inverted  cone  bur.  In  opening  up  pulp  chambers  the 
operator  should  avoid  disturbing  the  floor  of  the  pulp  chamber,  particu- 
larly in  molar  teeth,  for,  as  has  already  been  alluded  to,  the  floor  is  a 
guide  to  the  entrance  of  the  root  canals  and  makes  the  finding  of  each  a 
simple  matter.  I  wish  to  deprecate  the  use  of  round  burs  for  the  purpose 
of  opening  pulp  chambers,  for  with  them  the  chamber  floor  is  so  liable 
to  be  cut  and  the  entrance  to  the  canals  filled  with  fine  chips,  making  it 
almost  impossible  to  locate  and  enter  a  broach  in  them. 


Fig.  25A. 

All  of  this  work  must  be  done  under  the  most  thorough  antiseptic 
precautions.  The  dam  must  always  be  in  place,  the  field  of  operation 
cleansed  and  dried,  the  immediate  tooth  cavity  sterilized  and  dried  with 
alcohol,  the  broaches  and  other  instruments  used  must  be  sterilized,  and 
from  the  time  you  open  the  chamber  nothing  should  ever  enter  except 
such  instruments  and  agents  as  are  placed  there  by  the  operator.  After 
the  chamber  has  been  opened  the  cavity  should  again  be  flooded  with 
alcohol  to  wash  out  all  loose  fragments  and  then  dried  with  warm  air ; 
the  drying  has  a  tendency  to  shrink  the  pulp  tissue,  making  its  removal 
all  the  easier.  The  next  step  is  to  remove  the  large  bulbous  portion  of 
the  pulp  with  the  pliers  or  a  spoon  excavator.  In  many  cases  where 
sodium  hydroxid  has  previously  been  sealed,  the  entire  pulp  will  come 
away  with  the  pliers  or  excavator ;  indeed,  I  have  several  such  speci- 
mens preserved  that  were  taken  from  molar  teeth  in  this  manner. 


79 

A  fine  broach  is  then  passed  along  the  walls  of  the  various  canals  to 
explore  and  locate  any  irregularities,  after  which  a  barbed  broach  is  car- 
ried along  the  wall  well  into  the  canal  and  turned  just  sufficient  to 
entangle  the  pulp,  when  it  will  easily  come  away  in  one  piece;  this  will 
nearly  always  be  true  in  large  canals,  but  oftentimes  canals  are  too  small 
to  admit  of  even  the  finest  barbed  broach  with  safety,  for  the  danger  of 
■catching  the  barbs  in  the  dentine  is  very  great  in  small  canals,  with  the 
result  that  a  portion  of  the  broach  is  left  in  the  canal,  which  is  a  very 
difficult  thing  to  remove.  In  these  small  canals  I  have  been  using  for 
several  years  the  Downey  or  Ivory  twist  of  spiral  broach.  With  a  little 
experience  they  can  be  turned  into  almost  the  smallest  canal,  not  only 
removing  the  pulp  but  enlarging  the  canal  slightly.  After  the  pulp  is 
removed  the  walls  of  the  canals  should  be  scraped  to  remove  the  odonto- 
blasts that  may  be  clinging  thereto.  This  can  be  done  in  all  but  the 
smallest  canals  with  the  barbed  broach  by  introducing  and  withdrawing 
without  turning  or  rotating  it.  It  is  considered  best  not  to  disturb  these 
walls  further  than  this  in  all  except  the  very  smallest  canals ;  but  in  these 
small  canals  it  is  often  necessary  to  enlarge  them  in  order  that  they  may 
be  filled.  The  Downey  broach  is  admirably  adapted  for  this  purpose,  but 
the  point  needs  to  be  dulled  a  little  in  order  to  prevent  it  boring  through 
the  side  of  the  root  in  tortuous  canals.  This  broach  should  not  be  turned 
into  the  apex  before  withdrawing  and  cleaning  it,  but  it  should  be  turned 
in  and  back,  little  by  little,  withdrawing  and  cleansing  every  few  moments. 

There  still  remains  some  very  small  inaccessible  canals  that  cannot 
be  cleansed  in  this  manner,  and  for  this  several  methods  have  been 
suggested. 

First- — The  use  of  50  per  cent  sulphuric  acid  to  cut  the  soft  tissue 
and  dissolve  a  little  of  the  dentine,  thereby  enlarging  and  cleaning  the 
canal.  It  should  be  introduced  on  zephyr  wool  fiber  with  a  platina 
iridium  broach ;  except  in  rare  instances  it  should  not  be  allowed  to 
remain  in  the  canal  but  a  few  minutes,  after  which  it  is  neutralized  with  a 
solution  of  sodium  bicarbonate.  This  preparation  is  specially  valuable 
in  loosening  pulp  nodules  and  tumor-like  deposits  occurring  sometimes 
in  the  canals. 

Second — The  use  of  pulp  digestors  such  as  carica  papaya,  dissolved 
in  slightly  acidulated  water  and  allowed  to  remain  sealed  in  the  chamber 
for  10  to  20  days. 

Third — Mummifying  paste,  for  which  I  have  no  respect. 

When  the  canals  have  been  thus  mechanically,  and,  when  need  be, 
chemically  cleansed,  they  should  be  flooded  with  alcohol  worked  well 
down  to  the  apex ;  this  will  wash  up  all  loose  particles ;  clean  and  dry 
the  canals,   in   which   condition   thev  are   ready   for  the  filling.     At  this 


8o 

point  I  want  to  emphasize  the  value  of  mechanically  cleaning  the  canals 
rather  than  relying  on  medicines  to  do  this  work.  This  point  was  well 
emphasized  by  Dr.  Logan  in  an  article  read  before  one  of  our  societies 
recently. 

Many  operators  advise  the  filling  of  root  canals  immediately  after 
removing  the  pulp,  and  if  the  work  of  cleansing  has  been  thoroughly 
done,  with  all  precautions  against  infection,  it  would  seem  advisable  after 
bathing  in  some  mild  antiseptic  like  my  eucalyptol,  oil  cloves,  trikresol 
mixture,  and  again  drying  with  alcohol.  This  procedure  is  permissible  in 
those  cases  where  sodium  hydrate  has  been  applied  following  the  arsenic, 
but  in  all  other  cases  it  is  wisest  to  allow  the  dressing  before  alluded  to 
to  remain  for  a  few  days  in  order  to  be  certain  of  our  conditions  before 
root  filling. 

Tilling  Pulp  Canals. 

There  is  no  subject  in  operative  dentistry  that  has  received  so  much 
attention  in  the  last  15  years  as  has  the  proper  filling  of  pulp  canals,  and 
yet  the  ideal  filling  material  has  not  been  found.  First  came  cotton,  then 
wood,  followed  by  gold,  charcoal,  tin,  wool,  chloride  of  zinc,  paraffine, 
gutta-percha,  and  lastly  balsam  varnish — but  none  are  ideal. 

The  ideal  root  filling  should  be  non-porous,  non-irritating,  non- 
shrinking,  and  of  such  a  nature  that  it  can  easily  be  placed.  Such  a  ma^ 
terial  we  have  not,  but  the  most  nearly  ideal  material  we  have  at  the 
present  time  is  gutta-percha,  and  is  the  one  that  is  most  universally  used. 

The  technique  of  using  this  material  for  the  filling  of  large  canals 
is  to  first  select  a  small  piece  of  conical  shape  that  by  exploration  you 
have  decided  will  close  the  apical  foramen.  The  dry  and  sterile  canal  is 
slightly  moistened  with  eucalyptol,  all  excess  removed  and  with  the  aid 
of  a  properly  shaped  root  canal  plugger  the  selected  piece  of  gutta-percha 
is  slightly  heated  and  packed  in  the  apical  end,  completing  the  operation 
by  packing  piece  upon  piece  until  the  whole  canal  is  tightly  filled,  using 
hot  air  to  soften  when  needed. 

In  smaller  canals  it  is  customary  to  select  a  gutta-percha  cone  small 
and  stiff  enough  to  admit  of  being  forced  to  the  apex  ;  the  canal  is,  as 
before,  slightly  moistened  with  eucalyptol  and  chlora-percha — that  is, 
gutta-percha  dissolved  in  chloroform — is  pumped  into  the  canals  with  a 
fine  smooth  broach.  In  the  very  small  canals  much  care  must  be  exer- 
cised and  the  pumping  continue  for  a  considerable  time  to  force  the  chlora- 
percha  clear  to  the  apex,  then  the  selected  cone  is  carried  to  place  gently, 
allowing  the  excess  chlora-percha  to  escape  back  into  the  cavity  and  not 
forced  beyond  the  foramen.  Where  the  canals  are  very  small  fine  14k. 
gold  and  also  copper  points  are  made  to  take  the  place  of  the  gutta-percha. 
They  are  much   stififer  and  so  can  be  forced  where   so  small  a   gutta- 


8i 

percha  cone  would  not  go.  In  the  larger  canals  the  walls  only  should  be 
coated  with  chlora-percha  and  the  gutta-percha  cone  placed.  As  the 
chloroform  evaporates  the  gutta-percha  should  be  warmed  and  again 
packed  in  order  to  fill  in  the  shrinkage.  Many  use  eucalypto-percha, 
others  sandarac  varnish  instead  of  the  chlora-percha.  The  object  to  be 
attained  is  to  completely  fill  the  canal  and  not  force  any  material  beyond 
the  foramen.  While  this  is  a  very  delicate  matter,  a  little  practice  will 
develop  that  intuitive  perception  that  will  enable  one  to  do  it  well ;  the 
slight  flinching  of  the  patient  is  only  valuable  when  we  know  by  our 
sense  of  touch  that  it  is  the  filling  at  the  apex  that  is  the  cause  and  not 
air.  It  is  impossible  to  accurately  describe  the  filling  of  root  canals.  Tt 
is  an  operation  which  only  the  trained  finger  touch,  as  elsewhere  in  the 
field  of  operative  dentistry,  will  make  the  successful  operator. 


CHAPTER  X. 

Suppuration  of  tbe  Cootb  Pulp. 

Immunity  and  Susceptibility.     Kinds  of  Pus.      Fever.      Symptoms    of   Fever.      Sup- 
puration of  the  Pulp.     Cases  of  Open  Cavities.      Cases   of   Putrefaction 
Under   Fillings.     Treatment. 


Suppuration. — The  formation  of  pus ;  the  act  of  becoming  converted 
into  pus,  is  the  definition  given,  I  think,  by  most  authorities.  Thus  far 
we  have  for  the  most  part  been  studying  inflammation,  which  I  have  en- 
deavored to  show,  when  confined  within  certain  Hmits,  is  purely  a  process 
of  repair.  When  the  heahng  process  becomes  infected  with  bacteria, 
then  we  have  what  is  termed  an  infected  inflammation,  a  condition  unlike 
simple  inflammation,  which  shows  a  tendency  to  confine  itself  to  a  local 
area  and  to  heal ;  when  it  once  becomes  infected  it  shows  a  tendency  to 
spread  and  take  in  the  neighboring  parts  and  no  tendency  to  heal.  In  our 
study  of  inflammation  of  living  tissue  we  stopped  with  the  exudate  of 
coagulable  lymph  into  which  tissue  building  cells  congregate,  and  grad- 
ually transformation  into  granulation  tissue,  and  then  fibrous  tissue  and 
healing  is  completed  by  the  growth  of  epithelium. 

Let  us  return  to  our  case  at  the  point  where  tissue  building  cells 
are  gathering  in  this  coagulable  exudate,  and  here  introduce  an  element 
which  often  unexpectedly  appears  always  uninvitedly,  namely,  certain 
micro-organisms.  We  see,  then,  a  most  interesting  process,  usually  re- 
sulting in  suppuration,  but  not  always.  Sometimes  we  will  have  the 
presence  of  pus  forming  bacteria  in  these  inflammations  in  considerable 
numbers  and  no  perceptible  suppuration  occurring.  Why?  This  is  a 
point  I  wish  to  clear  up  first. 

First — The  condition  of  the  germ  with  which  we  infect. 

Second — The  condition  of  the  whole  cells  in  the  part  infected. 

Third — The  condition  of  the  whole  organism,  constituting  what  is 
known  as  immunity. 

Tmmunity  and  Susceptibility. 

Immunity  is  the  condition  in  which  the  body  as  a  whole  animal 
organism  resists  the  entrance  of  disease  producing  germs,  or,  when  they 
have  entered,  resists  their  growth  and  pathogenesis.  The  opposite  of 
which  is  the  term  susceptibility,  in  which,  instead  of  resistance,  favorable 
conditions  are  present  for  the  growth  of  these  germs  and  their  patho- 
genesis. 

The  study  of  immunity  and  susceptibility  is  perhaps  the  most  inter- 
esting of  all  physiology  and  pathology. 


83 

Man  suffers  from  many  diseases  which  are  never  observed  in  the 
animal.  The  laity  have  always  explained  this  fact  by  saying  that  animals 
.are  different  from  man ;  but  the  more  the  scientist  contemplates  this  sub- 
ject the  more  complex  it  becomes,  and  today  the  whole  investigation  is 
only  in  its  infancy.  It  was  early  thought  that  the  chemistry  of  the  body 
constituents  would  explain  all,  and  indeed  this  has  a  very  important  part 
in  it ;  but  it  does  not  explain  why,  for  example,  the  white  mouse  is  espe- 
cially susceptible  to  anthrax,  while  the  house  mouse  is  almost  immune 
to  its  ravages.  Nor  is  this  the  most  remarkable  thing  about  the  subject. 
Why  does  one  attack  of  yellow  fever,  smallpox  or  typhoid  fever  render 
the  subject  practically  immune  to  the  second  attack? 

And  furthermore,  a  few  drops  of  blood  taken  from  the  mouse  recov- 
ered from  tetanus  injected  into  another  renders  it  immune  to  that  dis- 
ease. These  are  some  of  the  interesting  things  that  we  observe.  I  want 
you  to  get  the  various  explanations  for  this  thing,  because. if  there  is  one 
subject  a  dentist  should  be  familiar  with,  it  is  the  subject  of  pus  forma- 
tion, how  it  occurs,  what  it  does  when  it  does  occur,  etc. 

The  first  theory,  perhaps,  is  known  as  the  Exhaustion  Theory. 
Pasteur  explained  this  im.munity  by  saying  that  the  micro-organisms  had 
used  up  all  of  som.e  certain  material  in  the  body  which  is  essential  to  the 
growth  of  these  germs;  hence  they  die  from  exhaustion,  i.  e.,  from  lack 
of  food.  Hence  the  removal  of  this  material  by  any  means  will  perma- 
nently remove  all  liability  to  disease  produced  by  these  germs.  Stern- 
berg pointed  out  the  weakness  of  this  theory.  He  said  if  it  were  true  we 
must  have  in  our  body  a' variety  of  this  material,  of  smallpox,  of  measles, 
of  scarlet  fever,  and  a  hundred  others  to  be  exhausted  by  its  appropriate 
organism,  and  shows  how  exceedingly  complex  and  stable  the  chemistry 
of  the  body  must  be  in  order  to  make  this  theory  hold  good. 

The  second  theory  is  known  as  the  Retention  Theory.  In  the  same 
year  that  Pasteur  and  Sternberg  were  working,  Chauvan  pointed  out 
the  fact  that  probably  the  progress  of  any  disease  may  develop  in  the 
system  a  substance  which  hinders  its  further  growth.  There  seems  to  be 
a  large  amount  of  truth  in  this ;  but  if  entirely  true,  what  amount  of  ma- 
terial and  how  many  different  kinds  would  be  added  to  our  blood  in  case 
we  had  smallpox,  measles,  scarlet  fever,  typhoid  fever  and  all  the  rest. 
Following  this,  in  1881,  Carl  Rosser  showed  the  relation  of  phagocytosis 
to  immunity.  Similar  observations  were  made  by  Sternberg  in  the  United 
States  and  Koch  in  Germany.  This  theory  was  more  thoroughly  and 
fully  developed  by  Metschinoff  in  1884  advancing  his  theory  regarding 
the  process  in  a  long  series  of  experim.ents,  he  showed  the  relation  of  the 
leucocytes  to  bacteria.  The  phagocytes,  which  we  have  alluded  to  in 
a  previous  chapter,  are  cells  without  maich  resisting  cell  wall   and  are 


84 

capable  of  amoeboid  movement.  Outside  of  the  body,  if  we  place  the 
amoeba  in  a  suitable  liquid  containing  bacteria  although  the  amoeba  pos- 
sesses neither  nervous  system,  eyes,  nose,  or  volition  of  any  kind,  it  will 
nevertheless  seek  out  these  bacteria.  They  surround  the  bacteria  and 
really  digest  it  completely.  The  property  which  enables  it  thus  to  find 
the  bacteria  I  have  explained  under  the  head  of  chemotaxis.  This  is 
exactly  what  takes  place  in  the  body,  and  is  what  I  have  alluded  to. 
Metscliinofif,  a  man  who  has  done  perhaps  more  of  real  scientific  work  than 
any  living  man  along  this  line,  succeeded  in  catching  some  of  these  leuco- 
cytes, each  containing  an  anthrax  spore.  After  inoculating  his  subject 
with  anthrax  he  succeeded  in  getting  any  number  of  these  wandering 
leucocytes  containing  anthrax  spores  within  themselves.  He  placed  them 
in  culture  media,  which,  of  course,  was  ill  suited  to  the  life  of  the  leuco- 
cytes but  better  so  to  the  bacteria,  and  watched  the  result.  The  leuco- 
cytes died  and  the  germs  lived  and  grew.  Taking  this,  then,  and  the 
amoeboid  movement,  we  have  the  process  of  suppuration  and  immunity 
as  explained  by  Metschinoff,  which  is  known  as  the  Metschinoif  Theory 
of  Phagocytosis. 

A  word  further  in  explanation  of  the  action  of  leucocytes  upon  bacteria.. 
Hankin  and  Hardy  found  three  varieties  of  leucocytes  had  a  part  to  play 
in  the  process,  the  outline  of  which  is  given  in  ]\IcFarland's  work  on 
bacteriology.  Hankin  and  Hardy,  taking  up  Metschinoff's  suggestion, 
went  to  work  to  study  just  the  kind  of  leucocytes  that  have  to  do  in  this 
thing.  They  found  that  certain  eosenophilic  cells  approach  and  swallow 
up  the  bacteria ;  then  certain  other  cells,  known  as  the  hyalin  cells,  take 
up  the  remains  left  by  the  former  cells  and  destroy  it.  Another  cell, 
which  is  known  as  the  basophilic  cell,  supposed  to  be  antidotal  to  the 
poisons  surrounding  the  combatants,  neutralizing  the  bacteria  poisons  and 
setting  free  the  contestants. 

We  have  another  theory  which  I  want  to  call  your  attention  to,, 
known  as  the  humoral  theory,  a  theory  worked  out  by  Buchner.  In  short,, 
it  is  this,  that  the  serum  of  the  blood  possesses  certain  germicidal  powers 
which  may  be  destroyed  by  heat,  fever,  etc.  Jetter  claimed  this  was  due 
to  certain  salts  contained  in  solution  in  this  serum.  Hankin  thought  this 
action  was  due  to  some  substance  contained  in  the  eosenophilic  cells. 
In  no  field  has  so  much  experimental  work  been  done  as  in  this.  At  the 
present  time  the  relation  of  the  blood  serum  is  not  exactly  understood. 
The  experimentation  has  given  rise  to  the  present  theory  of  antitoxin., 
which,  as  I  have  previously  stated,  is  at  present  in  its  infancy.  In  short, 
it  is  a  process  of  cultivating  germs  in  the  living  body,  and  taking  the 
serum  of  this  subject  at  a  certain  point  when  it  contains  poisonous  prod- 
ucts of  these  germs,  and  the  tissue  change,  and  injecting  in  man  to  im- 


85 

munize  him.  And  this  same  process  is  now  being  developed  to  include 
immunity  from  infection.  To  what  extent  this  theory  will  carry  us  the 
future  alone  can  decide.  Space  will  not  permit  me  to  go  further  into  the 
subject.  I  simply  wanted  to  bring  enough  of  these  theories  to  your 
attention  to  furnish  a  rational  basis  for  what  I  have  to  say  about  sup- 
puration. 

Let  us  return  to  our  consideration  of  suppuration,  and  perhaps  this 
little  apparent  digression  may  aid  us  in  comprehending  what  does  occur. 
The  cells,  indeed  the  whole  tissue  involved  in  the  process  of  repair, 
may  possess  sufficient  vital  force  to  withstand  the  onslaught  of  these 
micro-organisms,  and  they  are  literally  destroyed  and  carried  away,  and 
we  have  no  infection,  which,  of  course,  is  Metschinoff's  theory  regarding 
non-infection.  Every  operator  I  know  has  had  abundant  experience  to 
demonstrate  the  fact  that  simply  introducing  through  the  skin  some  in- 
fectious material  does  not  always  bring  infection.  I  know  that  many  of 
3^ou  have  already  pricked  your  fingers  with  broaches  and  exploring  in- 
struments that  you  knew  were  infected  and  had  no  result.  Another  time, 
you  do  not  know  how,  you  have  pricked  your  finger,  and  the  first  thing 
you  know  you  have  a  swollen  finger,  it  begins  to  get  sore  and  you  have 
the  whole  process  of  inflammation  and  suppuration  going  on  m  it.  Sup- 
puration is  a  subject  which  has  challenged  the  attention  of  the  brightest 
minds  among  scientists  for  many  hundred  years,  and  the  opinions  of  men 
have  undergone  most  radical  changes  within  the  last  thirty  years,  and, 
indeed,  I  may  say  that  it  is  only  within  the  last  fifteen  years  that  the 
cause  of  pus  formation  is  at  all  understood.  Up  to  that  time  the  theory 
advanced  by  Bilroth,  and  afterwards  elaborated  upon  by  Conheim, 
seemed  to  satisfy  most  minds.  This  theory  is  briefly  stated  thus:  Sup- 
puration consists  in  an  enormous  multiplication  of  the  cells  of  the  part 
due  to  diapedesis  of  leucocytes,  and  that  the  fluid  portion  of  the  exudate 
fails  to  coagulate,  and  this  with  the  softening  of  intercellular  substance 
produces  liquefaction  of  the  forming  tissue  and  pus.  So  far  as  it  goes, 
it  is  correct,  so  far  as  we  know.  The  only  addition  made  since  is  to  show 
exactly  why  the  exudate  fails  to  coagulate. 

Bilroth's  theory  was  that  we  have  this  great  multiplication  of  cells 
out  into  the  forming  tissue.  The  serous  exudate  fails  to  coagulate,  lique- 
faction of  tissue  forming  cells  and  pus.  All  we  have  done  to  that  in  the 
last  thirty  years  has  been  to  try  to  clear  up  and  explain  why  this  exudate 
fails  to  coagulate. 

Suppuration  is  a  bacteriological  process.  The  process  by  which  this 
has  been  brought  out,  although  exceedingly  interesting,  I  can  only  hint 
at.  Scientists  generally  agree  with  Bilroth  and  other  experimenters  as  to 
what  is   seen  in  the   suppurating  tissue.        Everyone   agrees  that   what 


86 

Bilroth   and   Conheim   and  others  saw  at  that  time  in  the  tissue   was. 
.  correct. 

Lister,  in  1869,  threw  some  light  as  to  how  this  liquefaction  occurs. 
He  called  attention  to  the  many  micro-organisms  found  in  the  invaded 
1  issue,  as  had  also  Pasteur,  and  suggested  that  perhaps  they  had  some- 
thing to  do  with  the  process.  Lister  probably  was  the  first  to  clear  up 
this  subject  at  all.  In  proof  of  his  claim  that  perhaps  these  micro-organ- 
isms had  something  to  do  with  it,  he  set  about  to  exclude  bacteria  from 
wounds  and  see  what  the  result  would  be.  This  he  started  out  to  do  in 
wounds  made  by  the  surgeon.  It  was  just  a  little  before  this  that  the 
value  of  carbolic  acid  becamie  understood  as  an  aid  in  treating  suppura- 
tion. Lister  then  operated  under  a  carbolic  and  water  spray.  He  first 
sprayed  the  whole  room  in  which  he  was  operating ;  the  patient  was 
cleansed ;  the  part  to  be  operated  upon  was  thoroughly  cleansed  and 
sprayed,  and  after  he  had  finished  his  operation  the  wound  was  covered 
with  gauze  and  over  this  gauze  cotton  to  keep  the  air  away,  and  thus 
prevent  the  ingress  of  micro-organic  life  from  the  air.  The  world  was 
surprised  at  his  results.  He  had  no  suppuration.  Up  to  this  time  the 
surgeon  always  looked  forward  to  the  time  when  this  appearance  of  sup- 
puration, or  this  sort  of  liquid  or  exudate  would  appear  on  the  surface 
of  the  wound,  or  establishing  of  the  secretions,  and  as  the  pus  appeared 
he  would  look  at  it  and  examine  the  nature  of  it ;  under  certain  circum- 
stances this  is  healthy  pus,  we  will  get  healing  right  away  here,  believing 
that  the  suppuration  was  a  necessary  part  of  the  process  of  healing.  But 
Lister  excluded  all  of  these  bacteria,  .operated  under  antiseptic  conditions 
and  he  had  no  suppuration,  but  exactly  what  part  the  micro-organisms 
played  in  the  process  he  did  not  know.  He  was  read}^  to  believe  that 
micro-organisms  had  something  to  do  with  inflammation.  He  thought 
the  degree  of  inflammation  was  somewhat  dependent  upon  the  number 
of  these  germs.  This  was  away  back  in  1869.  In  1881  he  was  still  of 
the  opinion  that  they  were  not  a  necessary  part  of  pus  formation  in  all 
cases. 

So  far  as  I  can  learn,  Volkman  was  the  first  to  declare  that  without 
micro-organisms  we  could  have  no  pus.  This  was  in  1881.  A  school 
was  soon  developed  with  Henter  at  its  head,  which  had  for  its  motto : 
"No  pus  without  bacteria."     This  brought  out  most  violent  opposition. 

Bilroth  maintained  that  the  bacteria  were  an  accompaniment,  not  an 
essential  part  of  suppuration.  Pasteur  was  able  to  produce  suppuration,, 
with  pus,  in  which  he  had  destroyed  all  germs  by  heat  of  no  C,  leaving 
only  the  chemical  products  of  those  organisms.  For  the  purpose  of 
testing  this  idea  severely  men  tried  to  produce  suppuration  with  chemical 
irritants  only — croton  oil,  turpentine,  mercury,  etc.     Their  results  were 


87 

unsatisfactory,  although  many  succeeded  to  their  own  satisfaction.  A 
number  were  convinced  that  such  a  thing  could  be  done,  but  the  truth, 
doubtless,  is  that  they  infected  their  tests  either  from  without  or  within 
the  circulation,  because  they  would  succeed  on  one  animal  in  producing 
pus  and  fail  on  two  or  three.  The  method  was  to  make  a  fresh  wound 
under  aseptic  precautions.  A  small  glass  phial  charged  with  some  con- 
centrated irritant,  as  oil  of  mustard,  was  placed  in  the  wound  and  the 
wound  sewed  over  and  allowed  to  heal.  After  the  healing  had  occurred 
the  flask  was  broken  and  the  contents  forced  into  the  tissue.  A  hard 
swelling  and  severe  inflammation  was  the  result,  but  usually  no  pus.  When 
pus  did  occur  it  doubtless  was  due  to  the  presence  of  germs  somewhere 
in  the  tissue  or  circulation,  and  carried  there,  a  thing  which  occurs  very 
frequently ;  hence  surgeons  will  not  perform  a  severe  operation  when  there 
is  a  pus  forming  process  going  on  somewhere  else  in  the  body.  A  thing 
that  was  noticed  of  course,  in  the  cases  where  they  succeeded  in  producing 
pus  by  chemical  irritants,  was  that  in  this  pus  there  were  great  colonies 
of  bacteria,  always.  They  were  never  able  to  get  the  pus  without  finding 
bacteria  in  it.  Today  it  is  fairly  conceded  among  pathologists  that  we 
have  no  pus  with  micro-organism.s.  A  word  as  to  how  micro-organisms 
do  their  work.  Dr.  Black  says:  "Pus  formation  consists  in  the  fermen- 
tation and  liquefaction  of  plastic  exudate  thrown  out  in  the  process  of 
inflammation.  It  seems,  therefore,  necessary  that  we  have  inflammation' 
and  inflammatory  exudate  before  we  can  have  any  pus  formation."  This 
inflammatory  exudate  is  completely  studded  with  leucocytes,  as  we  have 
already  explained,  into  this  substance  wander  these  micro-organisms.  If 
the  germs  possess  sufflcient  vital  force  and  the  condition  of  the  exudate 
is  so  lowered  as  not  to  be  able  to  resist  them,  they  find  lodgment  and 
perform  all  the  functions  of  life,  and  in  this  process  a  peptonizing  ferment 
is  formed,  which  in  turn  liquefies  the  exudate,  little  by  little,  and  being 
filled  with  these  reparative  cells  all  is  carried  away  in  the  form  of  pus. 

Then  suppuration  takes  place  in  the  tissue  by  virtue  of  the  peculiar 
peptonizing  or  digestive  action  which  the  bacteria  exert  upon  the  tissue. 
In  the  beginning  the  same  changes  occur  as  in  inflammation.  Some 
oedema  of  the  part  is  first  observed.  At  the  same  time  leucocytes  are 
accumulating,  the  intercellular  substance  is  gradually  undergoing  trans- 
formation, and  as  you  approach  the  point  of  pus  formation  there  is  an 
mcreasing  number  of  leucocytes  and  some  red  blood  cells  with  increasing 
liquefaction  of  this  intercellular  substance,  and  pyogenic  germs  abound. 

As  the  virus  acts  more  and  more  intensely  on  the  part,  the  entire 
structure  breaks  down,  being  digested,  as  it  were,  by  the  chemical  pepton- 
izing substance,  and  the  tissue  liquefies  and  floats  away  a  fluid  pus  instead 
of  solid  material. 


This,  then,  is  the  process.  Remember  first  we  must  have  inflamma- 
tion and  the  inflammatory  exudate. 

Second,  we  must  have  bacteria  before  Ave  can  have  pus. 

Kind$  of  Pu$. 

We  have  several  varieties  of  pus,  and  it  is  subject  to  constant  change 
liepending  somewhat  upon  the  location  and  form  of  the  disease  as  well 
xas  the  condition  of  the  patient.  When  pus  is  of  a  yellowish  white  color, 
;and  about  the  consistency  of  cream  it  is  usually  composed  of  a  large 
number  of  pus  globules,  and  is  known  as  healthy  or  laudable  pus.  You 
have  observed  when  you  have  abscesses  filled  with  this  kind  of  pus,  that 
when  you  once  evacuate  the  abscess  and  disinfect  the  part  you  have 
recovery  immediately. 

It  is  the  sort  of  pus  from  which  recovery  is  readily  made. 

When  pus  is  thin  and  reddish  and  streaked  with  blood  it  is  called 
fcanious  pus,  and  very  frequently  is  mixed  with  particles  of  fibrin  and  dead 
tissue.  This  sort  of  pus  is  mostly  seen  in  certain  bone  diseases.  When- 
ever you  have  caries  of  the  maxillary  bones  you  will  always  have  this 
kind  of  pus  and  in  phagedenic  ulcers  abscesses  that  have  been  standing 
sort  of  dormant  for  years,  and  tumors,  etc.  On  opening  into  a  tooth 
whose  pulp  is  dead,  the  kind  of  pus  that  comes  away  will  determine  some- 
what the  condition  beyond  the  apex.  If  you  have  the  yellowish  white 
pus  you  have  a  condition  not  to  be  dreaded  very  much,  but  when  thin  red- 
dish pus  comes  sweeping  down  through  the  cavity  you  have  a  condition 
affecting  the  bone,  almost  always,  and  a  condition  that  is  going  to  be 
slow  to  heal. 

Then  watery,  acrid  pus  is  termed  ichorous  pus,  and  Is  common  to 
chronic  ulcers  and  certain  bone  diseases.  When  coming  from  the  mucous 
membrane  pus  is  called  muco-pus.     From  the  serous  membrane,  sero-pus. 

Thick,  ropy  pus  of  syphilitic  abscesses  is  termed  gummy  pus.  When 
the  sanious  pus  contains  flakes  of  coagulated  fibrin  it  is  called  cheesy  pus. 
It  is  a  sort  of  pus  that  very  frequently  is  seen  in  the  bone  abscesses  in 
abscesses  of  the  superior  maxillary  bon?,  for  instance,  wherever  pus  is 
sort  of  confined  under  pressure,  you  will  get  pieces  of  white  coagulated 
fibrin  in  the  pus. 

In  the  suppurative  process  we  usually  have  as  an  accompaniment, 
fever.  It  is  usually  an  accompaniment  of  inflammation  and  suppuration. 
Indeed,  it  always  occurs  in  acute  suppuration.  Whenever  you  have  an 
acute  alveolar  abscess  forming,  if  it  be  any  way  violent  in  nature,  if  it 
lias  developed  very  rapidly,  you  will  always  have  the  patient  presenting 
fever,  as  indicated  by  your  thermometer. 


89 

fewer. 

What  is  fever?  An  abnormal  elevation  of  the  body  temperature. 
In  hyperemia  or  simple  inflammator}^  conditions  we  have  a  rising 
temperature  in  the  part  due  to  increased  oxydization  on  account  of  the 
increased  blood  cells,  but  this  is  not  fever,  strictly  speaking.  Only  when 
we  have  a  rise  in  the  whole  body  temperature  do  we  regard  it  as  fever. 
In  ordinary  acute  alveolar  abscess  we  sometimes  have  a  rise  in  tempera- 
ture to  loi,  up  to  105  in  severe  cases.  I  want,  if  I  can,  to  impress  upon 
you  the  value  of  using  this,  as  a  diagnostic  aid. 

Often  patients  will  present  suffering  severe  pain.  Often  they  will 
present  with  a  tooth  very  sore  and  you  wonder  whether  or  not  the  process 
of  suppuration  has  started  in  or  whether  you  simply  have  a  case  of  apical 
pericementitis.  If  you  will  take  your  thermometer  and  put  it  under  the 
tongue  and  find  a  rising  temperature  to  10 1,  you  can  make  up  your  mind 
that  the  patient  is  being  poisoned  w4th  the  pus.  This  fever  is  the  result 
of  the  poisonous  products  of  micro-organic  life.  To  understand  it  thor- 
oughly a  knowledge  of  the  laws  governing  the  mechanism  of  heat  pro- 
duction and  heat  dissipation  is  essential.  The  normal  temperature  in  a 
state  of  health  is  98  4-10,°  or  37  C,  which  is  practically  stable,  varying 
slightly  in  torrid  and  frigid  zones.  The  body  is  constantly  producing  heat 
by  the  process  of  combustion,  oxygen  being  taken  up  by  the  tissue  and 
carbonic  acid  eliminated.  Enough  heat  is  produced  daily  to  raise  the  body 
temperature  forty-eight  degrees  Centigrade,  an  amount  far  beyond  possible 
life.  Then  there  must  be  an  arrangement  by  which  this  heat  is  liberated 
and  the  whole  process  is  carefully  balanced  in  order  that  the  temperature 
remain  stable.  If  we  take  a  large  amount  of  food,  or  unusual  exercise, 
an  increased  amount  of  heat  is  produced ;  during  sleep  or  repose  the 
amount  is  decreased.  The  red  face,  moist  skin,  increased  respiration, 
and  all  are  evidences  of  this  regulating  process  at  work.  The  increased 
amount  of  heat  production  is  offset  by  the  increased  amount  of  blood  in 
the  surface  being  cooled.  You  must  remember  that  the  temperature 
lowers  slightly  as  we  get  away  from  the  center  of  the  organism.  The 
surfaces  of  extremities  are  normall}'  cooler  than  the  thorax  contents.  The 
extra  heat  produced  by  food  is  rapidly  carried  to  the  surface  to  supply  the 
tissue  and  be  cooled.  The  point  I  want  to  bring  out  is  that  there  is  an 
automatic  arrangement  which  seems  to  protect  the  body  from  ordinary 
changes  to  which  it  is  subjected.  The  mechanism  or  arrangement  only 
works  within  certain  limits.  All  heat  produced  in  the  tissue  is  produced 
by  assimilation  of  nitrogenous  material  brought  about  through  the  nervous 
and  partly  by  the  muscular  tissue,  and  is  a  chemical  process  in  which 
oxygen  is  absorbed  and  carbonic  acid  given  oft".  Anything  that  will 
increase  the  amount  of  heat  produced  and  at  the  same  time  interfere  with 


90 

its  dissipation,  will  produce  fever.  When  a  patient  gets  a  temperature 
of  105  the  nurse  immediately  understands  that  she  must  bathe  the  body  in 
cold  water,  the  philosophy  of  which  is  simply  the  cooling  of  the  blood 
through  the  surface.  So  long  as  fever  does  not  endanger  the  burning  up 
of  tissue  it  is  not  a  dangerous  thing,  consequently  it  is  not  the  habit  of 
controlling  fever  by  systematic  medication  in  typhoid  fever,  and  such,  but 
by  the  constant  cooling  of  the  surface.  Indeed,  in  typhoid  fever  many 
cases  are  bathed  ten  and  a  dozen  times  in  twenty-four  hours  with  cold 
water. 

Symptoms  of  Tcver. 

The  early  symptoms  of  fever  is  a  sense  of  lassitude  or  malaise,  and 
if  you  examine  the  patient  you  will  find  there  is  a  slight  rise  in  tempera- 
ture and  rapidity  of  the  pulse.  The  skin  of  the  head  and  body  feels  warm 
to  the  touch,  although  the  extremities  may  be  cold.  If  the  attack  is  severe 
and  the  temperature  rises  rapidly  this  condition  is  followed  immediately 
b)^  what  is  known  as  a  chill.  The  skin  is  cold,  particularly  in  the  extremi- 
ties ;  usually  looks  pale  or  slightly  purple,  accompanied  with  involuntary 
chattering.  This  will  last  for  an  hour  or  two,  and  is  quickly  followed 
by  a  sense  of  heat,  flushed  face.  During  the  chill  the  patient  crouches 
over  the  fire  and  wants  to  be  covered  with  blankets,  etc.,  when  the  chill 
passes  they  want  the  clothing  removed  again.  If  the  fever  be  due  to  pus 
production,  or  rather  if  pus  poisoning  is  gradual,  there  will  usually  be  an 
absence  of  chill  with  but  little  fever.  In  all  acute  suppuration  we  have 
a  decided  rise  in  temperature,  as  I  have  stated,  loi,  102,  103,  104,  105 
or  even  106  occasionally  from  acute  alveolar  abscess. 

The  thermometer  is  a  diagnostic  aid  in  these  cases.  If  there  is  a 
chronic  case  where  a  large  amount  of  pus  is  present  we  v/ill  also  have 
some  fever.     What  is  it  that  causes  the  fever? 

Just  how  are  these  symptoms  brought  about?  We  stated  that  sup- 
puration was  purely  a  bacteriological  process. 

Can  the  same  be  said  of  fever?  Not  all  kinds  of  fever  are  due  to 
micro-organism  action  directly,  but  all  pyogenic  fever  is.  It  is  probably 
an  effort  of  Nature  to  rid  herself  of  some  irritant  which  may  be  the 
product  of  bacterial  action  or  of  the  bacteria  themselves.  This  irritant 
may  be  in  the  nature  of  a  ferment-like  substance,  or  in  some  cases  may  be 
the  result  of  cell  disintegration.  Bacteria  do  not  grow  well  except  in 
nearly  normal  temperature,  and  it  may  be  that  this  rise  of  temperature 
has  a  beneficial  result  in  inhibiting  the  growth  of  these  low  forms  of  life 
within  the  body.  Indeed,  this  is  the  late  idea  regarding  fever,  that  it  is 
simply  an  effort  on  the  part  of  Nature  largely,  to  throw  off  these  bacteria, 
Warren  says — "In  general,  it  may  be  said  that  fever  is  due  to  the  presence 


91 

in  the  blood  of  a  pyogenic  substance  of  an  organic  nature  that  may  have 
been  produced  by  bacteria.  That  is  the  most  common  way.  Second,  to 
the  presence  of  bacteria,  or  finally,  to  some  ferment-like  substance  which 
has  resulted  from  cell  disintegration." 

The  poisonous  products  of  bacteria,  known  as  leucomaines  and  tox- 
albumens,  act  directly  upon  the  nerve  centers  in  such  a  way  as  to  interfere 
with  the  mechanism  of  heat  production  and  heat  dissipation.  Sufficient 
has  been  said  regarding  suppuration  in  general  to  enable  the  reader  to 
follow  the  process  as  seen  in  the  tooth  pulp. 

Suppuration  of  the  Pulp. 

Putrescent  Pulps. 

In  the  chapter  on  inflammation  of  the  pulp  we  endeavored  to  show 
that  inflammation  sometimes  only  affects  small  areas  around  the  point  of 
exposure.  When  aft'ected  in  this  area,  by  some  of  the  active  pus  germs, 
rapid  liquefaction  of  the  exudate  and  pus  is  the  result.  If  there  be  a  ready 
way  of  escape  through  the  horn  of  the  pulp  out  into  the  cavity,  this 
process  may  be  slow  and  the  main  body  of  the  pulp  may  remain  alive  for 
some  time,  and  death  and  suppuration  come  gradually,  little  by  little, 
painlessly.  But  if  that  exit  is  closed,  or  nearly  so,  a  rapid  increase  of 
inflammation  will  soon  involve  the  whole  pulp  tissue,  perhaps  within 
eighteen  hours,  and  on  to  rapid  infection  and  suppuration  of  the  whole 
organ.  This  is  usually  painful  process,  lasting  from  twelve  to  twenty- 
four  hours,  and  sometimes,  unless  relieved  runs  directly  into  alveolar 
abscess.  Such  a  process  as  this  is  usually  what  occurs  when  we  cap  an 
infected  pulp  or  cover  in  some  infective  material.  These  cases,  after  once 
started  usually  work  rapidly,  and  pain  ensues  and  continues  say  about 
twenty-four  hours,  and  with  a  sudden  stop  the  pulp  is  all  dead,  and  may  be 
it  will  pass  on  to  the  peridental  membrane  and  the  tooth  becomes  sore  to 
the  touch,  and  alveolar  abscess  almost  certainly  will  follow,  although 
occasionally  in  robust  individuals,  persons  whose  circulation  and  elimina- 
tion are  good,  it  may  stop  for  a  time  and  all  soreness  pass  away.  The 
first  or  chronic  form  of  suppuration,  where  progress  is  slow,  little  by  little, 
is  the  most  common.  When  the  pulp  once  starts  to  suppurate  it  rarely 
recovers.  The  tissue  cannot  heal  by  cicatrization,  i.  e.,  it  does  not  cover 
over  its  injury  with  epithelium  as  other  wounds  do,  therefore  it  is  always 
liable  to  reinfection  in  case  the  tissue  does  throw  off  one  attack.  When 
you  open  into  these  cases,  say  when  simply  the  horn  of  the  pulp  is  sup- 
purated, you  at  first  decide  that  you  have  a  dead  pulp  to  deal  with,  but 
when  you  attempt  to  pass  your  fine  smooth  broach  through  the  opening  up 
into  the  canal,  you  suddenly  produce  pain ;  you  are  then  surprised  to  learn 
that  a  little  way  down  the  pulp  is  alive  and  normally  sensitive.     Oftentimes 


92 

it  is  fairly  healthy;  the  living  vital  portion  has  separated  itself  from  the 
suppurating  portion  by  this  wall  of  plastic  exudate,  similar  to  all  inflam- 
matory processes. 

That  is  the  usual  way  in  which  pulps  die  from  infection.  It  some- 
times happens  that  the  pulp  tissue  in  one  canal  in  a  three-rooted  tooth  will 
remain  alive  while  the  other  two  are  undergoing  suppuration.  I  think 
all  have  probably  seen  cases  where  a  typical  acute  alveolar  abscess  form- 
ing, upon  opening  the  tooth  two  canals  probably  filled  with  suppurating 
material,  and  the  other  canal  sensitive,  unable  to  enter  it  at  all.  Then, 
again,  the  suppuration  may  pass  along  down  the  center  of  the  tissue,  as 
shown  in  Fig.  25. 


Fig.  25. 
Chronic    inflammation    of  the   pulp.     B,   blood   vessels   crowded   with   corpuscles;    C,   nuclei   of 
inflammatory  cells.     CHopewell-Smith.) 


Pus  will  work  its  way  down,  following  the  direction  of  the  blood 
vessels  until  the  center  is  largely  destroyed  and  suppurated,  and  yet 
alongf  the  wall  next  to  the  odontoblasts  the  tissue  is  alive.  In  other  of 
these  cases  there  may  have  been  symptoms  of  hyperemia,  toothache  a  little 
while  at  a  time,  then  passing  away  completely.  Patients  will  say  that 
perhaps  six  months  or  a  year  ago  they  had  a  severe  toothache  in  a  tooth ; 
it  was  very  sensitive  to  thermal  changes.  By  and  by  it  all  passed  away, 
and  the  tooth  is  comfortable.  No  matter  what  the  symptoms  are  in  these 
cases,  you  must  rely  on  what  you  see  while  making  your  excavation  and 
exposing  the  pulp,  rather  than  outward  symptoms ;  the  latter  are  often 


93 

misleading.  I  repeat  here  for  emphasis  pulps  inflame,  suppurate  and  die 
in  this  slow  chronic  way  without  causing  the  patient  the  slightest  annoy- 
ance. 

Cases  of  Open  Cavities, 

"When  the  pulp  of  a  tooth  is  exposed  and  becomes  the  seat  of  that 
series  of  vascular  and  nutritive  disturbances — hyperaemia,  inflammation 
and  suppuration — eventuating  in  its  gradual  death_,  the  necrotic  portions 
undergo  putrefactive  decomposition.  Several  processes  are  in  operation 
at  the  same  time,  so  that  diJTerent  portions  of  the  pulp  exhibit  differences 
in  chemical  composition,  differences  in  the  nature  of  the  infection  and 
also  in  the  pathological  conditions  existing. 

For  example,  while  the  apical  portion  of  the  pulp  is  the  seat  of 
inflammation  and  suppuration,  the  portion  of  the  pulp  previously 
destroyed  through  these  processes,  is  the  seat  of  later  stages  of  chemical 
destruction,  until  that  portion  which  was  first  acted  upon  is  being  revolved 
into  the  end-products  of  albuminous  decomposition,  of  putrefaction. 

In  this  serial  decomposition  albuminous  substances  are  first  trans- 
formed into  peptones  and  allied  substances,  some  of  them  being  very 
toxic.  Compound  ammonias,  known  as  ptomaines,  or  animal  alkaloids, 
are  probably  next  formed.  Next  the  nitrogenous  bases-leucin,  tyrosin 
and  the  amins  (methyl,  ethyl,  and  propyl)  make  their  appearance  together 
with  organic  fatty  acids.  Next  aromatic  products,  indol,  phenol,  creasol, 
etc.,  and  finally  hydrogen  sulfid,  ammonia,  carbon  dioxid,  and  water. 

By  alternating  processes  of  hydration,  reduction,  and  oxidation,^ 
bodies  of  increasing  simplicity  of  chemical  composition  are  formed. 
Miller  found  in  the  deepest  portions  of  the  degeneration,  putrefying, 
pulps,  where  inflammation  and  suppuration  were  in  progress,  a  pre- 
ponderance of  small  cocci  and  diplocci,  and  proceeding  toward  the  open 
pulp  chamber  an  increasing  number  of  large  cocci,  several  forms  of 
bacilli,  vibrios,  and  other  spirillae,  spirochaetae,  and  long  thread  forms. 

Until  infection  of  the  pericementum  occurs  these  cases  give  rise  to 
no  symptoms,  except  odor. 

Cases  of  Putrefaction  Under  Tillings. 

When  a  filling  is  placed  over  an  infected  pulp,  or  when  the  pulp 
dies  subsequent  to  the  insertion  of  the  filling,  the  organ  undergoes 
decomposition,  the  decomposition  being  carried  on  in  this  mstance  witn 
the  access  of  air,  i.  e.,  is  accomplished  by  anaerobic  organisms. 

Miller  found  that  bacteria  of  pulp-putrefaction  cultivated  in  gela- 
tin, with  and  without  the  access  of  air,  exhibited  a  difference  in  the 
poisonous  properties  of  their  products.  Those  developed  with  free  access 
of  air  produced  reaction  and  more  extensive  suppuration  than  those 
developed  without  the  access  of  air."' — Kirk. 


94 

treatment. 

What  shall  be  done  for  these  cases? 

Should  they  ever  be  capped  ?     No,  for  they  will  all  die. 

Shall  we  proceed  to  devitalize  at  once?  No,  not  until  the  suppura- 
tion has  been  stopped — the  reason  therefor  relates  to  the  fact  that  the 
presence  of  dried  suppuration  material  in  the  chapter  will  prevent  the 
arsenic  from  coming  in  contact  with  the  living  portion — and  also  there 
is  some  danger  of  setting  up  severe  pain  from  sealing  an  active  suppura- 
tive condition  without  proper  drainage.  It  is  not  considered  good  prac- 
tice to  attempt  pressure  anesthesia  in  these  cases.  There  is  great 
danger  of  forcing  the  infective  material  beyond  the  apex  and  causing 
a  most  violent  acute  abscess.  It  is  in  this  class  of  cases  where  the  pulp 
is  partially  dead  that  one  is  tempted  to  use  cocain,  but  in  my  hands  these 
cases  are  unfavorable. 

The  treatment  should  be  as  follows,  of  course  varying  somewhat 
to  meet  the  various  conditions  presented  where  the  pulp  is  completely 
dead  and  undergoing  suppuration,  the  first  steps  are  the  same  as  where 
a  portion  of  that  organ  remains  alive. 

The  rubber  dam  should  be  applied  and  the  field  sterilized,  cavity 
washed,  disinfected,  and  the  pulpal  wall  removed  as  thoroughly  as 
possible  avoiding  pressure  on  the  contents  of  the  chamber. 

I  find  the  inverted  cone  bur  very  helpful  for  this  purpose. 

The  next  step  is  to  absorb  away  with  cotton  any  exuding  pus  and 
wash  with  alcohol  and  dry  thoroughly  then  seal  in  a  good  antiseptic 
such  as  beechwood  creosote,  1-2-3,  or  camphophenique,  trikresol,  oil 
cloves,  etc.,  which  should  be  allowed  to  remain  from  24  to  48  hours. 
At  the  next  sitting  if  all  has  been  quiet  and  no  pus  present  arsenic  method 
of  destroying  vital  portion  may  be  followed.  In  case  the  entire  pulp  is 
dead,  and  suppurating  it  can  usually  be  thoroughly  mechanically  cleaned 
at  the  second  sitting,  and  one  of  the  agents  suggested  sealed  in  for 
another  48  hours,  when  the  canals  should  be  ready  for  filling.  In  man- 
aging these  cases  it  is  well  not  to  poke  around  in  the  canals  with  a  broach 
very  much  until  the  contents  have  been  disinfected. 

If  this  outline  is  carefully  foriov\^ed  and  no  infection  material  forced 
beyond  the  apex  the  treatment  of  putrescent  pulp  is  a  very  simple  matter. 


CHAPTER  XI. 

Cbe  Bacteria  of  Fu$. 


€.  $.  millard,  D.D.S. 

Constantly  present  in  the  atmosphere,  in  water  and  in  the  dust ;  in  the 
mouth,  on  the  skin  and  inhabiting  the  air-tracts  of  the  human  body,  are 
to  be  found  micro-organisms,  which,  for  the  most  part,  are  perfectly 
harmless.  Some,  however,  will  prove  to  be  pathogenic  when  a  lesion  or 
break  in  the  mucous  membrane  or  skin  (which  act  as  outer  defenses) 
affords  them  entrance  into  the  tissues,  or  when  some  other  abnormal 
condition  favors  their  multiplication. 

Of  these  micro-organisms  I  wish  to  speak  more  particularly  of  a  cer- 
tain few  which  seem  to  exhibit  pathogenic  characteristics  only  by  their 
ability  to  form  pus,  and  for  this  reason  are  known  as  Pyogenic  Bacteria. 
There  are  other  forms,  which,  under  certain  circumstances  produce  pus, 
but  are  not  classified  as  pus  producing  micro-organisms,  because  they 
are  more  strictly  identified  with  the  diseases  that  they  are  known  to 
cause. 

The  character  of  the  pus  produced  by  one  organism  does  not  dififer 
from  that  produced  by  another  organism.  In  fact  the  character  of  non- 
specific pus,  or  pus  that  may  be  produced  by  some  powerful  irritant  as 
croton  oil  or  carbolic  acid,  does  not  differ  from  specific  pus  or  that  pro- 
duced by  living  germs,  for  in  each  case  the  cause  is  chemical,  micro- 
organisms producing  pus  by  the  chemical  operation  of  their  enzymes  or 
digestive  exudates.  The  color,  odor,  or  quantity  of  pus,  however,  are 
■controlled  by  the  particular  species  growing  in  the  abscess. 

It  is  a  fact  known  to  bacteriologists,  that  where  disease  is  present 
as  the  cause  of  micro-organisms,  the  natural  flora  of  that  particular 
locality  is  in  some  cases,  entirely  absent,  while  the  specific  germ  of  the 
disease  dominates. 

In  suppurative  lesions,  while  there  are  many  cases  of  contamination 
of  species,  yet  quite  frequent  are  the  instances  where  pure  cultures  are 
obtainable  from  the  inoculation  of  culture  media  with  pus,  even  from 
localities  that  normally  are  teeming  with  varied  forms. 

Some  of  the  organisms  known  to  produce  suppurative  conditions 
are  as  follows : 

Staphylococcus  Pyogenes  Aureus. 

Staphylococcus  Pyogenes  Citreus. 


96 


Staphylococcus  Pyogenes  Albus. 

Streptococcus  Pyogenes. 

These  are  known  as  the  pus  cocci. 

Microccus   Tetragenus. 

Pneumococcus  or  Diplococcus  Lanceolatus, 

Gonococcus. 

Bacillus  Pyocyaneus. 

Bacillus   Typhosus. 

Bacillus  Coli  Communis. 

Streptothrix  Actinomyces. 

Many  other  forms,  among  them  some  of  the  yeasts  and  moulds, 
might  be  mentioned,  but  this  will  suffice,  and  from  these  I  will  select 
three  for  description  which  are,  strictly  speaking,  pus  producers. 

Name.  Staphylococcus  Pyogenes  Aureus.  Meaning  the  golden 
pus  producing  staphylococcus.     Fig.  26. 


Fig.  26. 

Staphylococcus  pyogenes  aureus  from  agar   culture.     (McFarland.) 

Morphology.  Spherical.  It  multiples  on  two  or  more  poles 
irregularly  taking  a  growth  form,  as  its  name  signifies,  after  the  manner 
of  a  bunch  of  grapes ;  groups  of  irregular  dimensions,  or  it  may  be  found 
as  single  cells  or  as  diplococci.  It  measures  ordinarily  about  .8  microns 
or  about  i/io  the  diameter  of  a  red  blood  corpuscle  i.  e.,  1/31000  of 
an  inch ;  and  it  has  been  estimated  that  one  grain  of  these  individuals 
will  number  something  like  125,000,000,000.  A  little  figuring  will  show 
that  a  space  measuring  about  i  cu.  millimeter  could  contain  1,952,625,000 
or  nearly  2,000,000,000  cells. 

Discovered  by  Rosenbach  in  1884. 

Origin.  It  is  the  most  common  of  the  pus  producing  organisms 
and  variously  estimated  as  present  in   from   50  to  80  per  cent  of  the 


07 

abscesses  examined.  It  might  be  said,  however,  that  in  abscesses  of  the 
mouth  the  white  variety  of  the  plant  is  more  frequently  met  with;  the 
staphylococcus  pyogenes  albus.  It  is  found  in  saliva,  on  the  skin,  in 
water,  on  particles  of  dust  floating  in  the  air  or  wherever  dust  may 
settle. 

Mobility.  It  has  no  motion,  having  no  flagella. 

Spores.     None.     It  multiplies  by  fission. 

Staining.  It  is  easily  stained  by  all  the  common  table  stains,  also  by 
gram. 

Growth.  It  grows  very  readily  on  all  the  ordinary  culture  media. 

Bullion  shows  a  cloudy  appearance  with  yellowish  sediment  and 
a  decided  acid  reaction. 

Gelatin  stab  culture  shows  decided  liquefaction  along  the  entire 
tract  of  the  needle.  The  growth  shows  a  yellow  precipitate  at  the 
bottom  of  the  liquefaction. 

Agar  slant  culture  shows  a  moist  golden  yellow  streak  on  the  surface 
of  the  media. 

From  all  of  these  cultures  a  peculiar  sour  or  acid  odor  is  noticeable. 

Aerobiosis.  It  grows  best  in  the  presence  of  oxygen,  where  it  pro- 
duces its  color,  but  will  grow  as  a  facultative  anaerobe,  and  as  such, 
produces  no  pigment.  The  optimum  temperature  is  about  'T^y  Centigrade, 
or  that  of  the  incubator,  though  it  will  grow  at  ordinary  or  room 
temperature. 

Pathogenesis.  The  staphylococcus  aureus  is  ordinarily  a  parasite 
though  it  will  grow  as  a  saphrophyte  as  is  seen  from  its  growth  on 
ordinary  culture  media.  Its  enzyme  separated  from  the  media  will 
produce  characteristic  pathogenic  results  in  the  formation  of  pus  in  living 
tissue.  This  organism  is  particularly  pathogenic  to  man,  and  external 
applications  of  pure  cultures  have  been  known  to  produce  suppuration  and 
carbuncles  (Garre),  while  inoculations  may  result  in  pyemia,  infection  of 
the  kidneys,  or  metastatic  abscesses.  The  infection,  however,  is  more 
inclined  to  be  local  and  less  violent  than  that  produced  by  the  strep- 
tococcus pyogenes,  and  is,  therefore,  not  very  serious.  Sterilization  may 
be  easily  effected  by  subjection  to  streaming  steam  or  the  application 
of  various  germicides.  Sterilized  cultures  contain  the  poisonous  pro- 
ductions of  the  germs,  and  will  produce  suppuration. 

Diagnosis.  Microscopic  observations  will  oftentimes  lead  to  a  sus- 
picion of  the  presence  of  the  staphylococcus  aureus  in  suppurative  areas, 
and  microscopic  examination  of  the  pus  with  artificial  cultivation  will 
reveal  the  characteristics  as  above  described. 

The  staphylococcus  pyogenes  citreus  and  the  staphylococcus  pyo- 
genes albus  are  considered  by  some  to  be  the  same  as  the  staphylococcus 


98 

pyogenes  aureus,  except  that  they  grow  under  different  conditions.  That 
they  are  of  the  same  species  there  seems  to  be  no  doubt,  for  all  that  may 
be  said  of  the  aureus  may  be  said  of  the  others,  unless  it  be  in  so  far  as 
color  and  virulence  are  concerned ;  the  albus  being  white  and  the  citreus 
producing  a  definite  lemon  yellow  pigment :  Again  it  is  the  common  opin- 
ion that  the  staphylococcus  aureus  is  more  virulent  than  the  citreus  and  the 
citreus  more  virulent  than  the  albus. 

Name.  Streptococcus  pyogenes,  this  of  all  the  pus  producing  organ- 
isms is  the  most  dreaded  by  the  surgeon.     Fig  27. 


Fig.  27. 
Streptococcus  longus  from  a  fatal   case  of  pyemia.    Magnified    1,000    times.       (Hopewell    Smith.) 

Morphology.  It  is  in  many  respects  similar  and  in  other  respects 
quite  unlike  the  staphylococci  just  described.  It  is  spherical  in  form. 
As  the  name  implies,  it  grows  in  chains,  multiplying  upon  one  pole.  These 
chains  may  be  of  greater  or  less  length.  Names  have  been  given  to 
supposed  varied  species  of  Streptococci  according  as  they  are  known  to 
assume  greater  or  less  length  of  chain,  as  Continuousum,  longus,  brevis, 
media,  etc.  Whether  these  are  varieties  of  the  same  or  of  different  species 
is  yet  a  question ;  it  is,  however,  certain  that  they  seem  to  exhibit  different 
physiological  phenomena  and  show  greater  differences  than  may  be 
noted  between  the  staphylococcus  aureus,  citreus,  and  albus.  Some  are 
not  known  to  produce  pus.  The  particular  form  under  discussion  dis- 
tinguished as  pyogenes  usually  extends  to  from  6  to  8  cells  in  length, 
though  oftentimes  in  bouillon  the  extension  will  be  to  upwards  of  a 
hundred  in  number.  In  size  the  cells  are  a  trifle  smaller  than  the 
staphylococcus. 


99 

Discovered  by  Rosenbach  in   1884. 

Origin.  In  abscesses,  pyemia,  erysipelas.  Found  in  the  mouth, 
Tiose  and  throat.  It  seems  to  find  its  natural  habitat  about  or  in  the 
vicinity  of  human  beings. 

Spores.  None  have  been  discovered.     It  multiplies  by  fission. 

Stains  by  all  the  common  table  stains  and  by  gram. 

Growth  is  readily  obtained  on  a  slightly  alkaline  medium,  though 
its  vegetative  function  does  not  seem  to  be  so  well  marked  as  in  the 
staphylococcus. 

Bouillon  growth  in  the  incubator  shows  at  times  a  clouded  medium 
with  white  precipitate,  again  the  medium  will  be  clear  with  the  white 
precipitate  at  the  bottom  of  the  tube,  and  also  attached  along  the  sides. 

Gelatin.  We  note  that  it  does  not  liquefy,  but  small  white  colonies 
are  formed  along  the  entire  track  of  the  needle  in  stab  cultures. 

Agar  slant  culture.  The  growth  is  very  slight,  looks  like  small  white 
drops  and  does  not  tend  to  run  over  the  surface. 

Aerohiosis.  Grows  best  in  the  presence  of  oxygen.  It  is  a  faculta- 
tive anaerobe.  Grows  at  37  Centigrade  and  gives  a  feeble  growth  at 
lower  temperatures. 

Pathogenesis.  This  organism  seems  to  be  more  particularly  a  human 
parasite.  It  is  pathogenic  to  man,  rabbits  and  mice,  and  its  virulence 
is  particularly  marked,  producing  spreading  inflammatory  infection, 
septicemia,  pyemia  and  erysipelas,  in  which  the  organisms  seem  to  infest 
the  lymph  channels.  Pure  cultures  of  streptococcus  pyogenes  may  at 
any  time  be  made  from  the  pustules  of  erysipelas  sores.  Most  of  the 
more  serious  suppurative  conditions  of  man  are  due  to  the  presence  of 
this  organism. 

Diagnosis.  Microscopic  observation  of  suspected  pus,  as  in  empye- 
.mia  of  the  antrum.  Artificial  cultivation  on  glycerine  agar  in  the  incu- 
bator and  intravenous  inoculation  of  rabbits. 


Name.  Bacillus  pyocyaneus.  The  micro-organism  of  green  pas. 
Pig.  28. 

Morphology.  A  rod  form,  small  in  size,  scarcely  exceeding  I 
micron  in  length  by  from  .3  to  .5  microns  in  width.  The  ends  are 
rounded.  It  is  sometimes  found  in  short  chains  but  nearly  always 
detached  or  as  single  cells. 

Discovered  by  Gessard  in   1882. 

Origin.  It  is  very  commonly  met  with  in  nature.  It  is  found  in  the 
air  on  particles  of  dust.  It  is  found  all  over  the  body,  and  in  the  internal 
organs  of  man  and  animals.  Pus,  when  infected  with  this  organism  or 
-caused  by  this  organism,  becomes  green  in  the  presence  of  oxygen. 


too 


^V  '^•-\=\>.v7  iJ .•>'•"'  ..•"'^  ■•',^    (!/ 


r'-^^yS; 


\ 


Fig.  28. 
Bacillus   pyocyaneus    from   an    agar    culture.      (McFarland.) 

Motility.  Active.     It  has  one  flagellum. 

Spores  have  not  been  discovered.     Reproduction  is  by  fission. 

Stains  b}-  all  the  common  anilin  dyes  and  by  gram. 

Grozvtli  is  readily  obtained  on  artificial  media. 

BouiUon  soon  becomes  cloudy  and  a  white  growth  soon  forms  on  the 
surface.  Very  early  in  the  growth  the  upper  part  of  the  medium  becomes 
green,  and  gradually  extending  deeper,  it  finally  becomes  brown. 

Gelatin  stab  cultures.  Liquefaction  occurs  along  the  track  of  the 
inoculating  needle.  A  white  growth  shows  upon  the  surface.  And  as 
in  the  case'  of  bouillon,  the  green  pigment  shows  at  the  top  of  the  gelatin, 
gradually  extending  downward  and  finally  becoming  brown. 

Agar  slant  shows  yelloAvish  or  whitish  slimy  growth  along  the  line 
of  the  inoculation  and  the  pigment  production  gives  the  same  indications 
as  in  gelatin. 

Potato  shows  a  brownish  slimy  growth :  oftentimes  no  green  appears., 

Aerohiosis.  Facultative  anaerobe.  The  organism  se^ms  to  grow  as 
well  out  of  the  incubator  as  in  it. 

Gas  production.  It  gives  off  different  gases,  and  has  a  character- 
istic aromatic  odor. 

Cliromo genesis.  Two  pigments  are  developed,  a  dark  brown,  or 
pyocyanin,  and  a  beautiful  deep  green,  or  fluorescin. 

Pathogenesis.  This  organism  shows  peculiar  phenomena;  at  times 
it  is  harmless,  and  again  decidedly  toxic.  Subcutaneous  injections  in 
guinea  pigs  produce  violent  inflammation  and  death.  Post-mortem 
examination  shows  bacteria.  Animals  infected  with  anthrax,  after  being- 
inoculated  with  the  bacillus  pyocyaneus,  have  been  known    to    recover. 


lOI 

Bacillus  tetanus,  known  to  be  an  obligate  anaerobe,  will  when  contami- 
nated with  the  bacillus  pyocyaneus,  grow  as  an  aerobe.  This  may  account 
for  many  deaths  by  lockjaw. 

Diagnosis.  It  is  most  often  discovered  by  the  green  pigment  which 
it  elaborates,  but  must  be  distinguished  from  the  bacillus  fluorescens  by 
its  liquefaction  of  gelatin  in  stab  cultures. 


CHAPTER  XII. 

Diseases  Hffecfiitd  tbe  FeriaeRtal  membrane  mm  tbe  J\p\m 
of  m  Roots  of  CeetD. 

Histological   Structures  of  the   Peridental  Membrane.    Functions.    Structures.   Cells.. 
Blood   Supply  Nerves.     Apical   Pericementitis.    Causes.    Symptom.   Treatment. 
Chronic  Apical  Pericementitis.     Cases.     Treatment.     Alveolar   Abscess. 
Causes.     Symptoms  and   Pathology.     Treatment.    Chronic  Alveo- 
lar Abscess.     Aneurysm.     Blind  Abscess.    Treatment  of 
Pulpless  Teeth.     Special   Cases. 


I)i$to1o0ical  Structures  of  tbe  Peridental  membrane. 

Before  considering  the  pathological  conditions  affecting  this  mem- 
brane it  seems  wise  to  briefly  review  its  histological  structures. 

The  peridental  membrane  is  the  soft  tissue  occupying  the  space 
between  the  tooth  root  and  the  alveolar  wall.  In  the  literature  it  is  often 
referred  to  as  dental  periosteum,  pericementum,  alveo-dental  periosteum. 

It  completely  surrounds  the  tooth  root  from  the  enamel  line,  and 
serves  as  a  connection  between  the  tooth  and  its  bony  socket  as  well  as 
gum  tissue.     It  is  thickest  in  childhood  and  thinnest  in  old  age. 

Tuttctions. 

This  membrane  differs  from  true  periosteum  in  that  both  its  surfaces 
are  functioning.  It  can  be  said  to  have  three  functions,  first,  a  physical 
function,  that  is  it  serves  to  maintain  the  tooth  in  its  socket  and  to  hold 
the  gum  around  the  tooth  neck.  Second — A  vital  function.  The  build- 
ing of  bone  on  the  alveolar  wall  and  of  cementum  on  the  tooth  and  it 
always  maintains  the  tooth  vitality  after  the  pulp  has  been  destroyed. 
Third — A  sensory  function.  It  not  only  transmits  pain  sensations,  but 
the  entire  sense  of  touch  is  supplied  by  this  membrane. 

Structures. 

The  peridental  membrane  is  made  up  of  dense  fibrous  tissue,  and  in. 
addition  has  certain  cells^  blood  vessels  and  nerves.  The  arrangement 
of  the  fibres  is  intended  to  hold  the  tooth  and  support  it  against  force  from 
every  direction. 

For  convenience  of  description,  histologists  divide  the  membrane  into 
three  portions,  first,  the  gingival  portion  which  includes  all  the  membrane 
just  under  the  free  margin  of  the  gum  and  over  the  border  of  the 
alveolus ;  second,  the  alveolar  portion,  which  includes  all  the  membrane 
from  the  alveolar  border  to  the  root  apex ;  third,  the  apical  portion  which 
surrounds  the  immediate  root  apex  and  occupies  what  is  known  as  the 
apical  space. 

If  we  examine  the  gingival  portion  under  the  microscope  beginning 
at  the  center  of  the  mesial  or  distal  we  will  observe  the  fibres  at  the 
enamel  junction  of  the  cementum  passing  out  from  the  cementum  at  right 


103 

angles  to  the  long  axis  of  the  tooth,  gradually  dipping  down  to  unite  with 
the  periosteum  of  the  alveolus  and  some  of  the  fibres  pass  directly  into  the 
gum  septum  and  others  pass  over  the  border  of  the  alveolus  to  mingle 
Avith  the  fibres  of  the  adjoining  tooth,  and  some  of  them  passing  directly 
into  the  cementum  of  that  tooth,  sometimes  called  dental  ligament. 
Fig.  29. 


Fig.  29. 
Cross  section  of  central  and  lateral  incisois    below    the   -im   of   the   alveolus   through   the    neck 
of  the  teeth.     A,  central;   b.  lateral;  c,  pulp  chamber  of  lateral;   d,  d,  cementum;   e,   e,  cementum; 
g,  g,  fibres   of  peridental   membrane;   h,  h,  j,  j,  epithelium.      (Black.) 

This  you  see  is  intended  to  hold  the  gum  septum  in  position  between 
the  teeth  and  hold  the  tooth  to  the  alveolar  border  as  well  as  to  the  neigh- 
boring tooth.  Passing  around  to  the  mesio-lingual  or  mesio-labial  you  will 
see  the  fibres  pass  out  and  turn  to  the  right  and  left  on  a  tangent  entering 
the  periosteum  and  gum  (see  Fig.  30).  These  are  intended  to  prevent  the 
tooth  from  rotating. 

On  the  labial  and  lingual  the  fibres  pass  out  at  right  angles  directly 
into  gum  and  periosteum  and  bone.  In  the  alveolar  portions  the  fibres 
coming  out  of  the  cementum  in  its  occlusal  portion  pass  at  right  angles 
into  the  alveolus,  while  a  little  nearer  the  apex  they  incline  occlusally,  and 
still  a  little  nearer  they  incline  still  more. 

In  the  ipical  portion  the  fibres  are  arranged  somewhat  fan-shaped 
over  the  apex.  These  fibres  often  pass  out  of  the  cementum  in  little 
bundles  and  split  up  before  entering  the  alveolus.  In  examining  the 
cementum  it  is  seen  that  these  fibres  do  not  all  penetrate  to  the  first  layer — 
that  is,  the  layer  immediately  over  the  dentine — some  pass  in,  only  the 
last  layer. 


104 


M  ^  » .,1^- p 


Fig.  30. 
Transverse   section   of  peridental   membrane    in  alveolar  portion.    M,  muscle  fibres,  periosteum; 
Al,  bone   of  alveolar  process;   Pd,   peridental   membrane;     Cm,     cementum;     P,    pulp;     D,    dentine. 
(Noyes.) 

Cells. 

The  cells  of  the  peridental  membrane  are — I,  Fibroblasts,  spindle 
shaped  cells  whose  functions  seem  to  be  the  building  of  membrane  fibres. 
II.  The  cementoblasts  which  lie  in  around  the  fibres  on  the  cementum  side ; 
their  function  is  the  building-  of  cementum  (Fig.  30).  Ill,  Osteoblasts, 
which  lie  in  around  the  fibres  on  the  bone  side ;  their  function  is  bone  build- 
ing. IV,  Osteoclasts,  oftener  called  myaloplaques  or  giant  cells.  They  are 
not  always  present,  but  seem  to  appear  at  times  around  among  the  fibres 
from  some  cause.  They  are  the  bone,  cementum  and  dentine  destroyers ; 
when  active  they  lie  down  close  to  the  bone  or  tooth.  They  sometimes 
seem  to  be  active  when  no  cause  can  be  assigned.  Often  cementum  and 
even  considerable  dentine  is  cut  away  and  again  filled  with  cementum 
(Fig.  31).  V,  Epithelial  cells.  There  is  a  set  of  cells  that  resemble 
epithelial  cells  which  group  themselves  together  so  as  to  appear  as 
epithelial  glands  (Fig.  32). 

Many  dispute  their  presence  and  think  what  is  seen  is  something  else, 
but  the  strongest  evidence  of  their  nature  is  the  fact  that  the  peridental 


105 


Fig.  31. 
Transverse   section  of   peridental   membrane    in   gingival   portion.     Ep,   epithelium;    Cm,   cemen- 
tum;    C)u-,   cementum   refilling  absorption;   Ec,   epithelial    cords    or   glands.     (Noyes.) 

membrane   has   a   secretive    function.      Many   substances    taken    into    the 
system  are  excreted  around  the  gum  margins. 


Fig.  32. 
Peridental    membrane  ne-xt  to    cementum   highly  magnified.     Fb,  fibroblasts;  Cb,  cementoblasts; 
7ot,  cementum;  D,   dentine;   Ec,  epithelial  cords  or  glands.     (Xoyes.) 


io6 

Blood  Supply  nerves. 

The  blood  supply  of  the  peridental  membrane  is  very  abundant- 
Blood  vessels  not  only  enter  at  the  apex,  but  from  the  bone  and  also  over 
the  alveolar  border,  and  are  distributed  everywhere  throughout  the  tissue 
twining  in  and  out  among  the  fibres.  The  capillaries  are  believed  to  be 
few.  The  nerves  enter  in  large  bundles  at  the  apex,  a  few  from  the  wall 
of  the  alveolus  and  a  few  over  the  alveolar  border. 

It  will  be  seen  then  that  this  richly  nourished  membrane  is  very 
dense  in  structure,  and  arranged  to  literally  suspend  the  tooth  in  its  socket 
and  hold  it  and  the  gum  in  position  against  all  direction  of  the  force  of 
mastication. 

Jfpical  Pericementitis. 

The  term  of  apical  pericementitis  is  applied  to  the  inflammation  of 
tha-t  portion  of  the  peridental  membrane  situated  about  the  root  apex. 
There  are  two  varieties  of  this  affection,  acute  and  chronic.  An  acute 
apical  pericementitis  is  an  inflammation  just  forming  and  characterized 
by  all  the  pathological  changes  which  occur  in  other  acute  inflammations. 

There  is  a  decided  thickening  of  the  membrane,  and  because  of  its 
bony  surrounding  it  is  a  painful  process. 

When  we  remember  that  the  sense  of  touch  in  the  tooth  lies  in  this 
membrane  it  can  readily  be  seen  why  this  is  such  a  painful  process. 

Causes. 

The  causes  of  apical  pericementitis  most  frequently  lie  within  the 
pulp  chamber,  but  not  always.  It  is  usually  dependent  upon  the  death  and 
putrefaction  of  the  pulp,  but  may  be  caused  by  a  great  variety  of  things 
such  as  a  shock,  severe  use,  unusual  stress,  irritating  substances  passing- 
through  the  canal,  following  pulp  extirpation,  root  fillings,  too  severe 
wedging  and  the  use  of  the  mallet  in  large  gold  fillings,  taking  cold,  etc, 
I  have  occasionally  observed  that  very  rheumatic  individuals  sometimes 
suffer  from  disturbances  of  this  nature,  which  is  only  temporary,  rapidly 
passing  away  when  the  constitutional  conditions  are  relieved.  In  its 
simplest  form  it  is  caused  by  the  hyperemia  or  inflammation  existing  in 
the  pulp  tissue  extending  through  the  apex  to  that  tissue. 

In  its  severest  form  it  is  caused  by  infection  from  pulp  putrefaction 
by  pyogenic  organisms. 

Symptom. 

The  most  prominent  symptom  and  the  one  always  present  in  acute 
cases  is  tenderness  to  percussion. 

Patients  complain  of  the  tooth  feeling  long,  occluding  before  the 
others,  and  for  this  reason  they  can  locate  it.  There  is  usually  some  slight 
redness  of  the  gum  tissue  opposite  the  apex  and  often  slight  tenderness 


I07 

to  digital  pressure  in  the  same  region.  There  is  an  actual  elongation  of 
the  tooth  due  to  the  thickening  of  this  membrane  forcing  the  tooth  down 
from  i'ts  socket.  To  percussion  the  tooth  has  a  dull  sound  and  if 
the  pulp  is  dead  there  will  be  the  absence  of  sensitiveness  to  thermal, 
changes. 

treatment 

In  acute  cases  the  treatment  is  very  simple. 

Remove  the  cause  and  put  the  part  to  rest.  If  the  cause  lies  within 
the  pulp  canal  then  that  must  receive  first  attention,  and  be  thoroughly 
cleansed  and,  so  far  as  the  membrane  itself  is  concerned,  it  will  take  care 
of  itself. 

Many  teeth  in  this  condition  are  lost  or  turned  into  chronic  form  by 
loo  frequent  medication,  especially  with  irritating  agents ;  however,  when 
the  canal  is  filled  with  putrescent  material  it  must  receive  careful  attention 
in  order  to  avoid  running  into  acute  alveolar  abscess.  This  treatment  has. 
been  fully  described  in  the  previous  chapter  and  all  I  wish  to  say  here  is. 
that  careful  instrumentation  is  the  essential  requirement  in  treating  these 
cases  together  with  mild  non-irritating  antiseptics,  and  rest.  Do  not  be 
poking  medicines  in  there  every  day  for  months ;  apply  your  remedy  the 
first  sitting,  change  it  in  24  or  48  hours,  and  mechanically  clean  the  canal, 
then  reapply  your  dressing  and  allow  to  remain  a  week  or  ten  days  when, 
in  the  great  majority  of  cases,  the  canal  filling  may  be  proceeded  with. 

Occasionally  we  meet  with  cases  that  do  not  yield  so  readily.  Pain 
continues,  and  must  be  met  by  other  means,  such  as  counter-irritants  with 
the  pepper  pads,  tr.  iodine,  chloroform  confined,  or  blood  letting;  some- 
times opening  into  the  apical  space  through  the  outer  wall  of  the  alveolus 
and  lacerating  the  tissue  will  be  helpful.  This  opening  can  be  made  by 
dipping  a  coarsely  saturated  plugger  in  95  per  cent  carbolic  acid  and  al- 
lowing this  to  touch  the  mucous  membrane  over  the  root  apex ;  then  rub- 
bing off  the  white  eschar,  repeat  until  the  bone  is  reached  when,  with  a 
proper  drill  in  the  engine,  you  can  penetrate  the  space  painlessly. 

This  should  be  supplemented  by  the  hot  foot  bath,  5  to  10  grains  of 
quinine  followed  by  small  does  of  tr.  aconite  and  tr.  gelsemium,  alternately, 
half  hour  for  6  or  8  hours,  and  at  bedtime  10  to  15  grains  of  Dovers 
powder,  followed  in  the  early  morning  by  a  copious  saline  cathartic. 

This  same  line  of  treatment  is  sometimes  indicated  in  acute  forming 
alveolar  abscess. 

In  acute  cases  where  there  is  no  perceptible  putrescence  in  the  canal 
don't  imagine  you  have  an  abscess  at  the  apex  because  of  the  tenderness, 
and  don't  try  to  enlarge  the  foramen  so  you  can  force  medicines  through,, 
but  lay  in  a  mild  antiseptic  and  let  it  rest  a  week  or  two. 


io8 

Where  acute  pericementitis  develops  while  devitalization  and  pulp  re- 
moval are  in  progress,  it  is  probable  that  the  operator  is  to  blame.  He  may 
have  been  careless  with  his  instruments  as  regarding  their  proper 
sterilization,  or  pushed  one  through  the  apex,  or  used  irritating  agents  in 
too  great  a  quantity  in  the  canal.  A  case  I  had  a  few  years  ago  illustrates 
the  point  I  wish  to  make.  A  well  known  dentist  devitalized  a  pulp  in  a 
central  incisor  in  a  gentleman  of  good  health  about  the  age  of  thirty-five. 
He  removed  the  pulp  and  sealed  in  some  oil  of  cloves  and  dismissed  the 
case  for  a  week.  Patient  returned  in  three  days,  tooth  sore  to  the  touch ; 
dentist  removed  dressing,  washed  out  and  sealed  in  fresh  dressing  of  the 
same.  Conditions  grew  rapidly  worse  and  he  concluded  he  had  some 
infection,  so  after  changing  again  he  sealed  in  oil  of  cassia  because  of 
its  reputed  great  antiseptic  power.  This  made  matters  worse  and  when 
patient  returned  he  could  hardly  bear  to  have  the  tooth  touched,  but  when 
the  dentist  did  succeed  in  removing  the  dressing  down  came  thin,  watery 
fluid,  and  he  at  once  concluded  he  had  violent  infection  and  left  the  root 
open.  Up  to  this  time  eight  weeks  had  been  consumed,  all  of  which  time 
patient  was  in  agony,  but  as  he  left  the  tooth  open  with  no  irritating  oil 
in  the  canal  it  rapidly  quieted  down.  Patient  returned  again  and  dentist 
sealed  in  his  powerful  antiseptic  with  like  results,  and  patient  removed 
the  dressing  himself,  which  the  dentist  had  recommended  him  to  do  in 
case  he  had  trouble.  By  and  by  there  was  real  infection,  as  you  can 
readily  see  from  leaving  this  canal  open.  They  battled  along  this  way  for 
a  year  and  a  half  until  the  dentist  became  alarmed  and  feared  serious 
necrosis  and  advised  extraction,  but  it  was  a  case  where  it  would  be  the 
only  tooth  the  gentleman  had  lost  in  his  upper  jaw  and  he  disliked  very 
much  indeed  to  lose  it.  So  he  brought  the  patient  to  me  for  counsel,  and 
after  examination  he  turned  him  over  to  me  to  make  a  trial.  I  cleansed  out 
the  tooth  thoroughly,  dried  it,  sealed  in  a  powerful  non-irritating  germi- 
cide, forcing  a  little  beyond  the  apex  into  the  cavity  absorbed  in  the  bone. 
And  let  me  say  that  when  I  saw  the  case  there  was  absorption  beyond  the 
end  of  the  root  almost  as  deep  as  the  length  of  the  root  itself ;  a  great 
pocket  there ;  of  course,  it  was  filled  with  pus.  The  agent  that  I  used  in 
that  particular  case  was  a  ten  per  cent  solution  of  chinosol,  which  I  will 
have  occasion  to  refer  to  later.  After  carrying  this  medicine  a  little  into 
the  absorbed  pocket  beyond,  I  sealed  the  cavity  and  instructed  the  patient 
to  return  in  five  days,  but  if  the  soreness  increased  markedly,  not  to  open 
it  himself,  but  to  return  at  once  to  me.  At  the  end  of  five  days  the  tooth 
was  completely  comfortable.  I  redressed  it  as  before  and  dismissed  him 
for  two  weeks.  On  examining  the  case  this  time  I  noticed  the  tissue 
rapidly  filHng  in  the  absorption.  I  redressed  it  and  dismissed  him  for  two 
weeks  more,  at  the  end  of  which  time  I  filled  the  root  with  no  unpleasant 


after  effects.  I  have  had  occasion  to  watch  the  case  and  have  seen  it 
within  the  last  two  months  and  know  that  it  has  never  given  any  trouble. 
This  is  typical  of  many,  many  cases. 

There  is  often  a  little  soreness  following  pulp  extirpation  and  the 
same  following  pulp  canal  filling.  Give  it  absolute  rest,  don't  try  to  put 
a  filling  in  or  otherwise  further  irritate  it.  The  point  is,  do  not  get  any 
irritating  oil  or  its  vapor  through  the  apex  in  cases  where  pulps  have  been 
devitalized  and  removed.  If  you  should  accidentally  do  so,  just  let  it  rest, 
do  not  disturb  it,  nature  soon  recovers. 

gbronic  Jlpical  Pericemcntltl$« 

Acute  apical  pericementitis  will  usually  naturally  terminate  in  one  or 
two  conditions,  namely,  either  in  acute  alveolar  abscess  or  in  chronic  apical 
pericementitis,  depending  quite  largely  on  the  nature  and  severity  of  the 
irritant. 

If  it  be  mild  nature,  somewhat  constant,  not  suppurative  in  its  nature, 
it  is  very  liable  to  terminate  in  the  chronic  form,  to  treat  which  often 
bafiles  the  skill  of  the  best  practitioners. 

Chronic  apical  pericementitis  presents  all  the  symptoms  of  the  acute 
in  modified  form.  Patients  usually  complain  of  much  or  little  soreness, 
which  may  have  extended  over  months  of  time  continuously,  or  the 
tenderness  may  come  and  go  every  few  days.  Usually  the  gum  is  a  little 
red  over  the  apex  and  slightiv  tender  to  digital  pressure.  I  have  met 
several  cases  where  there  was  a  decided  thickening  of  the  bone  over  the 
apex,  and  many  times  there  is  a  thickening  of  the  cementum. 

0a$c$. 

The  chronic  form  usually  follows  an  acute  attack  where  the  irritant  is 
mild  and  continuous,  sometimes  following  pulp  canal  treatment,  root  fill- 
ings, broken  broaches,  and  such,  but  most  frequently  is  the  result  of  very 
mild  putrescence  in  the  pulp  canals  where  pulps  die  under  fillings  or  from 
irritation  of  some  kind,  and  very  slowly  disintegrates,  just  enough  poison 
being  formed  to  keep  up  a  constant  irritation. 

Occasionally  we  run  across  a  patient  whose  peridental  membranes  are 
very  prone  to  inflammation.  I  usually  find  such  an  individual  suffers  from 
chronic  inflammation  of  all  the  mucous  membranes. 

treatment. 

The  management  of  these  cases  often  try  the  patience  of  the  operator.* 
The  technical  procedure  must  be  along  the  lines  already  mentioned. 
Relieve  the  tooth  by  grinding  its  occlusal  surface  or  that  of  its  opposite 
in  such  a  way  that  the  stress  of  closing  the  jaws  will  be  borne  by  the 
other  teeth.  I  sometimes  get  good  results  by  sealing  in  the  canal  well  up 
to  the  foramen  a  saturated  solution  of  iodine  in  creosote,  for  its  irritant. 


no 

alterative  effect.     Its  liability  to  cause  discoloration  is  its  chief  objection, 
and  so  must  be  cautiously  used. 

Sometimes  stirring  up  by  passing  a  smooth  broach  through  the  fora- 
men will  be  helpful.  A  3  per  cent  solution  of  formaldehyde  is  sometimes 
helpful ;  anything  that  will  cause  a  mild  increase  of  the  soreness  will 
usually  aid.  These  are  the  kind  of  cases  that  usually  get  sore  soon  after 
treatment  is  sealed  and  patients  either  open  the  approach  or  ask  the  den- 
tist to.  They  should  be  encouraged  to  bear  the  added  pain  for  a  little 
time  in  the  interest  of  permanent  cure.  What  I  said  regarding  treatment 
of  acute  cases  applies  here ;  do  not  keep  changing  the  dressings  every  day, 
but  leave  one  good  dressing  applied  on  cotton  in  the  canal  tightly  sealed 
for  two  weeks  at  a  time.  Many  times  for  a  second  treatment  I  have  used 
a  paste  made  of  hydronaphthol  with  trikresol,  and  left  it  in  the  canals  for 
six  weeks,  with  gradual  disappearance  of  symptoms  and  permanent  cure 
as  a  result.  No  hard  and  fast  rules  can  be  laid  down  for  treating  these 
■cases ;  the  good  judgment  of  the  operator  must  determine  how  to  manage 
each  individual  case  that  is  presented. 

Jllveoliir  Hbscess. 

An  abscess  is  a  collection  of  pus  within  the  tissues  which  is  always 
preceded  by  a  circumscribed  destructive  inflammation  which  results  in  the 
breaking  down  of  the  tissues  in  a  given  area.  The  term  alveolar  abscess 
has  been  arbitrarily  restricted  to  those  occurring  at  the  apical  portion  of 
teeth  or  the  apical  portion  of  the  peridental  membrane,  although  strictly 
speaking  any  abscess  occurring  in  the  alveolus  would  be  an  alveolar 
abscess  (Fig.  33).  These  abscesses  are  divided  into  two  general  classes, 
namely,  acute  and  chronic. 


Fig.  33. 

Showing  abscess  on  the  side  of  buccal  roots  of  an  upper  molar.      (Barrett.) 


Ill 


€au$e$. 

Acute  alveolar  abscess  occurs  when  apical  pericementitis  becomes 
■infected  with  pus  forming  germs.  It  is  always  dependent  upon  the  death 
of  the  pulp.  As  all  forms  of  apical  pericementitis  of  any  marked  degree 
can  onfy  occur  after  the  pulp  is  dead,  so  also  we  can  only  have  alveolar 
abscess  after  the  pulp  is  dead  and  infected.  For  here,  as  elsewhere,  we 
■can  have  no  pus  Avithout  pus  producing  micro-organisms.  When  the  in- 
flammatory condition  around  the  apex  becomes  infected,  usually  inflam- 
mation rapidly  increases,  sometimes  slowly,  being  governed  here  as  else- 
where by  the  condition  of  the  germs,  of  the  local  tissue  and  the  general 
.system. 

This  inflammation  causes  rapid  swelling  of  the  peridental  membrane, 
causing  the  tooth  to  be  lifted  out  of  the  socket,  unless  the  condition  of 
the  bone  beyond  offers  less  resistance.  As  in  severe  cases  of  apical  perice- 
mentitis the  tooth  is  actually  elongated;  patients  always  complain  of  the 
tooth  being  long,  being  in  the  way,  they  strike  it  before  they  do  the  other 
teeth  in  occluding.  And,  as  a  matter  of  fact,  the  tooth  is  elongated,  i.  e., 
it  is  actually  pushed  down  out  of  the  socket  by  the  swelling  of  the  mem- 
brane at  the  apex.  You  can  readily  see  why  this  must  be  such  a  painful 
process.  Indeed,  acute  alveolar  abscess  is  usually  the  most  painful  con- 
dition with  which  we  have  to  deal. 

We  divide  acute  alveolar  abscess  into  four  classes  according  to  the 
manner  of  the  escape  of  pus.  First,  where  the  pus  passes  through  the 
alveolus  into  the  soft  tissue,  producing  a  rounded  fluctuated  tumor 
directly  over  the  root  of  the  affected  tooth.  This  is  the  form  most  fre- 
quently met  with  and  is  most  easily  handled   (Fig.  34).     Second,  where 


Fig.  34. 
Acute    alveolar    abscess    of    upper 
central  incisor,  pointing  on  the  gum. 
A  J   abscess    cavity;    b,    floor    of    nos- 
tril; c,  lip;  d,  tooth.     (Black.) 


"the  pus  passing  through  the  alveolus  tears  up  the  periosteum,  a  thing 
■which  often  occurs  (see  Fig.  35,  also  Fig.  36). 


112 


I'lg.  35. 
Acute  alveolar  abscess  with  pocket 
of  pus  between  periosteum  and  bone 
A,  abscess  cavity;  b,  floor  of  nos- 
tril; c,  lip;  d,  tooth;  e,  pus  cavity 
beneath   the    periosteum.      (Black.) 


Fig.  36. 
Acute  alveolar  abscess  with  pus 
pocket  between  periosteum  and  bone 
of  palate.  A,  abscess  cavity;  b,  pus 
cavity  beneath  periosteum;  c.  lip;  d, 
tooth;   c.  floor  of  nostril.     (Black.) 

The  pus  here  has  passed  through  the  bony  process  and  has  taken  up 
the  periosteum  of  the  bone,  which  can  usually  be  determined  by  finding 
a  broad,  long,  flat  tumor,  sometimes  extending  two  or  three  teeth  mesially 
and  as  far  distally  as  the  last  tooth.  When  you  cut  in  with  a  lancet  you 
discover  an  area  of  some  size  denuded  of  the  periosteum. 

I  have  seen  many  cases  hold  pus  in  such  a  sac  for  days  and  show  a 
tendency  to  pass  along  towards  the  gingiva  and  discharge.  These  cases 
are  not  so  frequent  as  the  others,  but  every  practitioner  meets  a  consider- 
able number  every  year.  Usually  when  pus  is  discharged  they  get  well 
readily;  the  periosteum  reattaches  itself  to  the  bone.  After  the  pus  has 
discharged   it   will   usually  lie  back  upon  the   bone  and   reattach   itself. 


113 


Usually,  I  say,  but  sometimes  these  cases  terminate  seriously  by  the  de- 
struction of  large  areas  of  bone  as  a  result  of  tearing  away  the  periosteum. 
The  third  form  is  where  the  discharge  occurs  along  the  side  of  the 
root  between  the  peridental  membrane  and  the  tooth.  This  is  by  far  the 
least  frequent  of  all  forms  of  alveolar  abscess,  I  am  glad  to  say ;  but  it  is 


Fig.    37. 
Chronic  alveolar  abscess  at  root  of 
lower     incisor,      discharging      under 
chin.      ,-Jj    abscess    cavity;    b,    b,    b, 
fistula;   c,   lip;   d,  tooth.     (Black.) 


Fig.  38. 
Abscess  of  buccal  roots  of  upper  molar  discharging   on  the    face.     A,   abscess  cavity;    h,   pomi 
of   discharge   on    face;   c,  antrum;    /,   lip;   e,  tooth.      (Black.) 


114 

also  much  the  most  difficuU  to  handle  and  when  chronic  is  liable  to  be  mis- 
taken for  pyorrhea  alveolaris.  Fourth  class  is  where  the  pus,  instead  of 
making  an  exit  in  any  of  the  ways  indicated,  follows  along  the  sheath  of 
some  muscle,  or  its  fibres,  until  it  finds  an  easy  exit.  In  some  cases  it  may 
follow  until  it  reaches  the  muscle  attachment  to  the  bone  and  then  its  exit 
at  that  point.  You  may  set  down  a  rule  that  pus  will  always  go  in  the 
directir""  of  least  resistance.  Very  often  it  comes  to  the  skin  in  all  sorts 
of  places,  particularly  around  the  lower  jaw  (Fig.  37),  upon  the  cheek 
(Fig.  38),  under  the  eye,  in  front  of  the  ear;  when  they  open  on  the  face 
they  make  ugly  scars. 

Symptoms  and  Pathology. 

Tooth  feels  longer  and  strikes  occluding  teeth  before  others  do.  At 
first  the  striking  may  give  relief,  i.  e.,  when  the  inflammation  is  first 
started  up,  to  bite  on  the  tooth  may  feel  good.  But  it  soon  becomes  ex- 
tremely painful;  the  slightest  jar  causes  pain.  In  these  acute  cases  the 
patient  can  scarcely  lie  down  ;  temperature  and  pulse  go  up ;  agony  in- 
creases every  minute  until  it  becomes  almost  intolerable.  Let  me  say  that 
in  the  great  majority  of  cases  of  acute  alveolar  abscess  you  can  tell  what 
the  patients  are  suffering  from  by  seeing  them  come  into  the  office.  You  find 
the  patients  coming  in  walking  on  their  toes ;  they  don"t  want  to  set  their 
heels  down  because  the  slightest  jar  causes  pain.  And,  of  course,  they 
usually  have  the  expression  of  agony  written  upon  their  faces.  As  the 
inflammation  increases  the  bone  around  the  apex  begins  to  absorb  to 
accommodate  the  swelling  membrane  and  the  forming  pus.  On  and  on 
it  goes,  pus  forming  a  little  faster  than  space  to  accommodate  it,  and  the 
temperature  continues  to  rise.  By  and  by  one  or  more  Haversian  canal? 
running  into  this  space  begin  to  enlarge  or  absorb,  the  pus  follows  in 
these  canals  until  by  and  by  it  reaches  through  the  bone  to  the  soft  tissue. 
It  usually  goes  towards  the  labial,  rarely  towards  the  lingual,  although  oc- 
casionally. When  the  soft  tissue  is  reached  the  swelling  begins.  Pus  goes 
in  the  way  of  least  resistance.  The  swelling  continues  sometimes  to  enor- 
mous size  and  shape.  Pus  continues  to  burrow  in  the  way  of  least  resist- 
ance until  it  finally  approaches  the  surface  of  the  gum,  which  usually  puffs 
out  in  the  form  of  a  rounded  tumor  which  points  more  and  more  until 
finally  it  breaks  through  and  pus  is  discharged  and  pain  subsides.  Indeed, 
pain  begins  to  quiet  down  as  soon  as  the  pus  passes  through  the  bone  and 
the  swelling  begins. 

treatment. 

In  all  acute  cases  the  first  thing  to  attend  to  is  the  forming  tumor. 
Where  there  is  a  well  rounded  tumor  forming  on  the  gum  over  the  root 
apex  the  only  thing  needed  so  far  as  the  tumor  itself  is  concerned  is  to 


1^5 

let  the  pus  out  by  cutting  with  a  lancet  at  the  most  dependent  part.  I 
wish  to  emphasize  the  idea  of  cutting  by  drawing  the  edge  of  the  blade 
along  the  bottom  of  the  tumor  rather  than  attempting  to  puncture  it  with 
the  point  of  the  lancet.  The  latter  is  usually  painful  because  of  the  pres- 
sure exerted  on  already  distended  and  tightly  drawn  tissue. 

After  this  has  been  done  the  case  should  be  allowed  to  rest  for  a 
few  days  until  tenderness  has  subsided,  when  the  offending  pulp  cham- 
ber can  be  opened  and  proper  treatment  proceeded  with.  In  the  second 
class  it  is  necessary  to  make  a  free  long  incision  at  the  most  dependent 
part  of  the  tumor,  press  out  the  pus  and  thoroughly  irrigate,  examining 
to  see  if  an}-  necrosed  bone  be  present.  The  offending  tooth  then  is  al- 
lowed to  rest  until  soreness  has  subsided.  I  have  had  a  number  of  cases 
where  these  alveolar  abscesses  had  literally  torn  away  the  periosteum  from 
the  alveolus  around  two  or  three  or  maybe  four  teeth,  and  the  whole  mass 
of  bone  dead,  so  that  the  teeth  and  bone  and  all  would  come  out  with  the 
slightest  eft'ort.  This  is  a  thing  that  is  likely  to  occur  in  cases  of  serious 
accident,  people  meeting  with  traumatic  injuries,  etc.  These  cases  where 
surgical  interference  is  sometimes  necessary,  but  frequently,  and,  indeed, 
usually,  the  bone  will  be  thrown  off  in  a  large  mass,  and  if  the  periosteum 
remains  alive  it  will  gradually  rebuild  the  bone.  This  is  a  most  remark- 
able thing,  and  I  have  seen  some  of  the  most  remarkable  recoveries  where 
the  bone  became  necrosed  and  sloughed  off  a  large  area.  That  is  the  proc- 
ess by  which  all  fractures  are  healed,  so  that  you  do  not  need  to  worrv  in 
those  cases  where  the  periosteum  is  alive ;  but  if  the  periosteum  is  gone, 
then  your  case  is  hopeless.  In  these  cases  the  parts  must  be  made  clean, 
surgically  clean,  all  dead  bone  removed,  and  kept  clean  until  recovery  is 
complete.  In  the  cases  that  I  have  just  illustrated  in  Fig.  35,  when  you 
make  your  opening  with  the  lancet  and  have  all  the  pus  out,  always  take 
pains  to  wash  out  such  a  case  as  this,  cleanse  it  out  with  carbolized  water, 
differing  in  that  respect  from  the  rounded  tumors.  The  irregular  places 
in  which  pus  may  have  caught,  as  it  were,  make  it  necessary  that  you 
wash  it  out  with  carbolized  water.  Always  do  that  after  opening  this 
kind  of  a  case.  In  the  third  variety  there  is  usually  no  tumor,  although 
sometimes  the  pus  makes  its  way  out  into  the  gum  tissue  near  the  gingi- 
vus,  in  which  case  the  tumor  should  be  opened  and  drained.  AVhere  the 
discharge  is  along  the  peridental  membrane,  making  its  exit  between  the 
gum  and  the  neck  of  the  tooth,  the  pulp  canals  must  receive  immediate 
attention. 

In  the  fourth  class,  where  pus  is  attempting  to  make  an  exit  on  the 
skin  surface,  especially  about  the  face,  very  careful  attention,  too,  is  re- 
quired. When  a  case  comes  to  you  with  the  tissue  much  swollen  and 
hard  in  certain  areas,  never  poultice — please  bear  that  in  mind — but  dis- 


ii6 

courage  its  coming  to  the  surface  by  free  incision  in  the  mouth.  Let  us 
illustrate :  Take  a  case  where  the  swelling  is  on  the  lower  jaw,  perhaps  in- 
volving the  submaxillary  gland.  The  tissues  are  very  much  distended  and 
a  certain  area,  perhaps  the  size  of  a  twenty-five  cent  piece,  is  very  hard 
and  has  already  begun  to  get  red  or  purple  in  that  particular  region.  If 
you  poultice  that  a  few  days  it  will  break  on  the  outside.  Instead  of  that, 
as  soon  as  you  see  the  case  you  take  a  lancet  and  make  a  free  incision 
into  that  abscess  from  within  the  mouth,  drawing  out  the  cheek  and  mak- 
ing an  incision  clear  along  the  periosteum  of  the  bone  until  you  reach  the 
abscess  and  get  the  discharge  within  the  mouth.  Oftentimes  cases  will 
come  to  you  too  late  for  that  sort  of  thing,  that  have  perhaps  already 
broken  and  are  discharging  on  the  face.  Then,  in  that  case,  the  first  thing 
to  do  is  to  cut  off  that  discharge  as  soon  as  possible,  either  by  the  extrac- 
tion of  the  tooth,  in  case  the  tooth  can  be  spared,  or  making  this  incision 
in  the  soft  tissue  from  within  the  oral  cavity,  thereby  cutting  off  the 
discharge  from  the  external  surface. 

The  case  may  come  to  you  before  the  pus  has  appeared  beneath  the 
surface  of  the  gum ;  in  this  acute  condition  when  the  tooth  is  so. 
sore  you  can  scarcely  touch  it,  and  a  collection  of  pus  in  the  apical 
space ;  it  hasn't  even  penetrated  the  bone  yet ;  or  it  may  have 
gone  far  enough  for  the  pus  to  have  penetrated  the  bone  and  no  farther ; 
indeed,  that  is  quite  a  usual  condition  that  we  meet  with.  In  this  case, 
when  you  feel  certain  that  the  pus  has  already  passed  the  bone,  inject  a 
little  cocaine  and  make  a  deep  incision  over  the  root  clear  to  the  bone 
until  you  find  the  pus.  You  usually  will  be  able  to  detect  whether  the 
pus  has  escaped  through  the  alveolus  by  the  finger  gently  pressing  upon 
the  soft  tissue ;  you  will  get  the  slight  fluctuation  that  always  presents  after 
the  pus  has  passed  beyond  the  bone.  In  case  the  pus  has  not  reached  the 
periosteum,  is  still  confined  within  the'  bone,  what  shall  we  do  to  relieve 
that  case?  That  case  is  more  difficult  to  handle.  Many  dentists  send  pa- 
tients away  to  poultice  and  await  swelling  and  breaking  on  the  surface, 
which  seems  a  cruel  thing  to  do.  In  this  class  of  cases  it  has  been  my  cus- 
tom to  open  into  the  apical  space,  either  by  the  use  of  a  strong  knife  passed 
through  the  soft  tissue  and  bone,  after  having  anesthetized  the  parts  with 
cocaine,  or,  in  case  that  seems  impracticable,  the  bone  is  very  heavy  and 
I  do  not  succeed  in  that  method,  or  for  any  other  reason  I  decide  that 
this  is  not  practicable,  then  the  method  that  I  use  is  the  same  as  described 
for  opening  the  apical  space  in  apical  pericementitis. 

The  advantages  of  using  this  carbolic  acid  and  plugger  method  are 
two.  It  prevents  hemorrhage  and  can  be  done  painlessly.  Care  must  be 
taken  not  to  drill  into  the  tooth  root. 

When  it  is  possible  to  open  into  these  cases  directly  through  the  tooth 


117 

or  cavity  at  the  first  sitting,  it  is  always  advisable  to  do  so.  In  case  there 
is  no  cavity,  we  open  upon  the  lingual  or  occlusal  surface.  But  often  the 
teeth  are  so  sore  as  to  make  the  operation  impossible,  especially  if  we 
liave  to  open  in  through  sound  tooth  structure  or  a  filling.  Of  course, 
you  readily  understand  that  if  there  was  a  large  cavity  and  the  pulpal 
wall  was  thin,  there  would  be  very  little  difficulty,  even  though  the  tooth 
was  sore,  in  making  that  slight  opening ;  but  in  case  it  is  necessary  to 
drill  through  sound  tooth  structure  like  this,  or  a  filling,  they  are  often 
50  sore  as  to  make  it  quite  impossible. 

I  want  to  suggest  a  few  methods  that  will  often  make  this  possible. 
After  you  have  everything  in  readiness  for  opening,  place  the  finger  or 
thumb  of  the  left  hand  on  the  crown  of  the  tooth  and  begin  by  pressing 
gently,  increasing  gradually  until  you  have  accustomed  the  tooth  to  it ; 
then  hold  it  rigid  and  open  directly  with  a  rapidly  revolving  drill.  If  it 
were  a  molar  tooth  on  the  lower  jaw  I  probably  would  hold  it  v^dth  my 
thumb.  I  sometimes  take  the  sore  tooth  and  its  neighbor  between  the 
thumb  and  forefinger  in  a  tight  grasp,  thereby  holding  firm  and  prevent- 
ing much  of  the  jar  of  the  drill.  Another  method  is  to  surround  the 
sore  tooth  and  its  neighbors  with  plaster  of  paris.  That  is  a  metliod  I 
use  especially  where  teeth  are  very  loose,  and  it  is  very  serviceable. 

Let  us  take,  for  example,  a  lower  first  molar,  all  neighboring  teeth  in 
position.  We  decide  that  it  must  be  opened  and  we  are  going  to  try  to  open 
it  rather  than  take  the  chances  of  opening  through  the  soft  and  hard 
tissues.  First  dry  surfaces ;  pack  toward  the  tongue  and  toward  the 
cheek  with  cotton  to  keep  the  secretions  away;  then, mix  plaster  with  a 
little  salt  in  it  so  it  will  set  quickly,  and  cover  the  second  molar  and 
wisdom  tooth,  if  they  be  present,  clear  down  to  the  gum  on  either  side  as 
far  down  as  you  can ;  also  cover  the  sore  tooth  and  the  two  teeth  anterior  to 
it ;  then  before  it  gets  real  hard  remove  the  plaster  from  the  occlusal  sur- 
face of  the  tooth  upon  which  you  are  going  to  drill ;  then  let  the  whole 
thing  set  very  firmly.  This  will  often  help  when  the  tooth  is  quite  sore. 
Try  it  and  see.  Your  success  will  depend  upon  the  perfection  with  which 
you  get  your  plaster  around  the  tooth,  so  it  is  in  contact  with  all  the 
tooth  and  the  gum,  thereby  distributing  the  pressure  from  one  tooth  to  five 
teeth.  That  I  suppose  you  would  call  making  a  temporary  splint.  Where 
teeth  are  affected  with  pyorrhea  and  are  very  loose  and  it  is  necessary 
to  open  into  the  canal  (many  of  these  come  to  us  with  pulps  dead),  that  is 
the  method  that  I  use  almost  universally.  Then  another  method  is  to 
ligate  the  teeth,  beginning  with  the  second  molar,  tying  your  ligature  on 
the  mesial  surface  of  it,  then  around  the  sore  tooth  and  ligating  again  on 
the  mesial  surface  of  that,  and  then  around  the  second  bicuspid  in  the 
same  manner ;  passing  your  ligature  back  and  forth  in  that  way  bind  and 


ii8 

lock  rhe  teeth  solidly  together.  The  objection  to  that  method  is  that  it 
is  sometimes  painful  in  tying  the  ligature.  Otherwise,  it  is  very  useful. 
Another  method  that  I  use  very  frequently  is  to  tie  the  ligature  strongly 
around  the  neck  of  the  tooth  to  be  drilled  into,  and  then  with  the  thumb 
or  the  forefinger  I  catch  a  loop  of  the  ligature  and  gently  Hft  up  on  the 
tooth,  increasing  until  I  get  a  good  strong  pressure,  literally  lifting  the 
tooth  away  from  the  swollen  and  irritated  peridental  membrane ;  and  drill 
as  before.  Another  method  that  I  use  frequently  is  to  take  the  ligature 
and  tie  it  around  the  "sick"  tooth,  making  the  knot  distally ;  take  another 
one  and  bringing  it  around  the  tooth  and  making  the  knot  mesially ;  that 
gives  two  ligatures,  one  to  the  mesial  and  one  to  the  distal.  Then  take 
ligature  and  pass  it  from  the  mesial  around  to  the  distal  of  the  second 
molar,  and  tie  it.  Then  I  do  the  same  thing  with  the  second  bicuspid, 
having  the  ligature  tied  between  the  two  bicuspids,  bring  ligature  that  is 
on  the  distal  surface  of  the  second  molar  up  over  the  occlusal  surface  and 
the  one  on  the  distal  surface  of  the  first  molar  and  tie  over  the  occlusal  of 
the  second  molar  and  likewise,  the  one  on  the  mesial  of  the  second  bicus- 
pid and  on  the  mesial  of  first  molar  tied  on  the  occlusal  of  second  bicuspid. 
You  see,  this  actually  lifts  the  sore  tooth  out  of  the  socket,  a  thing  that  is 
very  simple  to  do,  is  not  painful,  and  is  very  successful. 

There  are  many  cases  presented  in  which  we  fail  to  give  relief  either 
because  of  the  nervousness  of  the  patient  or  the  severely  painful  condition 
present,  and  all  we  can  do  is  to  administer  such  general  remedies  as  will 
aid  the  sufferer  in  accordance  with  the  plan  suggested  in  the  treatment 
of  painful  pericementitis.  One  thing  in  addition  can  be  done^  and  that  is 
to  make  hot  water  applications  to  the  face,  which  will  tend  to  relieve  the 
pain  and  at  the  same  time  hasten  the  pointing  of  the  abscess.  We  should 
keep  in  mind  the  danger  of  hard  swollen  areas  breaking  on  the  face,  and 
discontinue  such  applications  where  this  tendency  is  shown,  although  my 
experience  has  been  that  where  moist  heat  is  used  that  danger  is  not  so 
great  as  where  dry  heat  is  used.  In  all  cases  we  should  seek  the  first  oppor- 
tunity to  make  an  opening  either  through  the  gum  or  into  the  pulp  cham- 
ber, and  thus  afford  relief,  and  avoid  those  serious  conditions  which  are 
liable  to  happen. 

Cbronic  Hiveolar  Hb$cc$$« 

The  tendency  of  all  acute  abscesses  is  to  become  chronic;  when  they 
discharge  their  pus  upon  the  surface,  either  of  the  skin  or  the  gum,  they 
frequently  Tieal  over ;  then  in  a  few  days  they  break  and  discharge  again, 
and  repeat  this  process  every  few  days  for  weeks  and  years.  Usually 
patients  with  such  cases  think  nothing  of  it  at  all ;  usually  painless.  After 
they  have  discharged  the  first  time  the  patient  will  come  to  you,  perhaps 


119 

telling-  you  that  a  little  swelling  occurs  in  a  certain  region  of  the  mouth ; 
it  puffs  up,  they  pass  their  fingers  over  it,  it  breaks  and  that  is  the  end 
of  it,  until  it  recurs. 

It  is  in  this  class  of  chronic  cases  that  we  have  the  worst  burrowing 
of  pus.  Little  by  little  the  pus  will  burrow  along  the  periosteum  of  the 
bone.  Take  a  case  where  it  has  discharged  upon  the  gum  and  heals  over 
(Fig.  39).     The  next  time  that  Nature  makes  an  effort  to  force  the  pus 


Fig.    39. 
Chronic  alveolar  abscess  at  root  of 
lower    incisor.      A^    abscess    cavity; 
bj    Estula    discharging    on    gum;    c, 
lip;    d,  tooth.     (Black.) 


out  through  that  tract  it  will  drop  down  a  little  lower  each  time,  until  by 
and  by  you  will  have  pus  burrowing  in  all  sorts  of  directions  (See  Figs. 
27  and  38).  I  have  had  some  very  remarkable  cases.  I  remember  one 
case  which  was  the  most  interesting  of  all.  It  w'as  during  the  early  years 
of  my  practice.  I  was  called  upon  to  extract  a  lower  wisdom  tooth  on  the 
right  side.  The  tooth  was  badly  broken  down,  was  not  paining  at  all,  but 
the  odor  from  it  was  offensive,  and  I  found  that  the  wisest  thing  to  do 
was  to  extract  it.  The  patient  told  me  that  she  suffered  at  times  with 
what  appeared  to  be  a  sort  of  paralysis  of  the  right  arm,  i.  e.,  it  would 
be  all  numb,  and  the  same  on  that  side  of  the  neck.  I  did  not  associate 
it  with  the  tooth,  but  after  extracting  the  tooth  and  washing  out  the 
socket  I  found  that  I  readily  forced  water  out  just  at  the  clavicle,  and 
upon  inquiry  I  found  that  she  had  a  place  that  was  discharging  there. 


120 


She  thought  it  was  a  tubercular  gland  and  had  it  opened  twice  by  a 
surgeon  and  the  bone  scraped,  .1  flooded  it  through  with  carbolized 
water  and  then  washed  it  through  with  a  twenty-five  per  cent  emulsion 
of  carbolic  acid,  when  it  healed  up  without  trouble. 

I  remember  another  case  that  I  had  where  the  discharge  was  just 
under  the  lower  jaw  about  the  region  of  the  submaxillary  gland.  I  was 
doing  some  dental  work  for  this  case  also;  patient  did  not  come  to  me 
for  treatment  of  this,  believing  that  it  was  a  cancer  there.  She  had  it 
opened  and  scraped  any  number  of  times ;  it  would  heal  up  and  be  all 
right  for  two  or  three  weeks  and  then  it  would  puff  out  again  and 
break  and  discharge.  On  making  a  filling  in  a  lower  first  molar  I  dis- 
covered that  the  pulp  was  dead.  I  opened  into  that  tooth,  cleaned  out 
the  root  canal  and  had  no  difficulty  in  washing  through  the  root  of  that 
tooth  right  through  this  opening.  In  that  case  the  pus  had  gone  directly 
through  the  bone ;  the  channel  was  directly  through  the  bone,  appearing 
on  the  under  side.  In  that  particular  case  we  were  able  to  save  the  tooth 
and  heal  up  the  difficulty  in  the  jaw. 

But  oftentimes  in  these  cases  where  pus  has  burrowed  either  through 
the  bone  or  along  the  periosteum  for  some  way  before  it  discharges  we 


b 

Fig.  40. 
Chronic  alveolar  abscess,  lower 
incisor  with  abscess  cavity  extending 
through  the  body  of  bone,  discliarg- 
ing  on  chin.  A,  abscess  cavity;  b, 
inouth  of  fistula;  d,  tooth;  c,  lip. 
(Black.) 


121 


have  serious  necrosis  of  the  bone,  and  it  does  require  something  of  a 
surgical  nature.  I  think  perhaps  you  have  all  read  of  the  interesting 
case  of  Dr.  Black  where  the  pus  had  burrowed  from  a  lower  central  in- 
cisor directly  through  the  jaw  (see  Fig.  40).  He  was  consulted  in  the 
matter  by  the  surgeon  who  was  handling  the  case  and  asked  if  he  thought 
the  tooth  might  have  anything  to  do  with  it,  and  he  said  he  would  be 
decidedly  of  the  opinion  that  it  might  have.  Then  they  wanted  to  know 
what  they  would  look  for  to  tell ;  he  told  them  that  perhaps  the  tooth  was 
loose;  perhaps  discolored  or  something  of  that  kind;  perhaps  it  had  a 
history  of  being  sore  once  upon  a  time,  or  something  of  that  kind.  They 
made  an  examination  and  decided  that  the  tooth  was  responsible  and  ex- 
tracted it  and  washed  down  through  the  socket  underneath  the  chin.  Then 
they  made  an  arrangement  whereby  they  tied-  a  string  on  a  sponge,  and 
saturated  this  sponge  with  medicine  and  pulled  it  through,  and  then 
pulled  it  back  again.  They  told  the  patient  it  was  a  very  serious  case 
and  had  her  coming  every  day  to  run  this  sponge  through  to  keep  it  clean 
and  open.  It  happened  that  she  lived  quite  a  little  ways  from  the  office, 
and  there  came  up  a  very  severe  storm,  making  it  impossible  for  her  to 
come  out,  and  I  believe  she  didn't  come  for  three  days,  and  when  she  did 
come  it  was  all  healed  up,  which  is  the  usual  thing.  These  cases  get 
well  readily  usually  where  the  pus  has  burrowed  without  much  difficulty, 
especially  where  it  has  not  met  with  much  resistance. 

It   is   probable   that  these   cases   discharge   more    frequently   in   the 
antrum  than  we  imagine  (Fig.  41).     If  you  will  examine  all  the  skulls 


Fig.  41. 

Alveolar  abscess  at  the  roots  of  upper  molar   discharging  into  the  antrum. 
■  b,  mouth   of   fistula;   c,    pus   in   antrum;    d,   nostril;   e,   tooth;    f,   lip.      (Black.) 


Aj  abscess  cavity; 


you  get  an  opportunity  to,  you  will  be  surprised  at  how  thin  the  floor  of 
the  antrum  is  in  many  cases,  and  I  am  sure  often  we  have  these  cases 
penetrating  the  antrum  when  we  do  not  realize  it ;  because  of  the  absence 


122 

of  pain  patients  frequently  do  not  know  of  the  trouble  until  severe 
empyemia  results.  In  chronic  cases  where  pus  is  discharging  on  the  gum 
or  other  surface  careful  exploration  should  be  made  through  the  sinus 
with  the  silver  probe  to  locate  its  direction  and  discover  if  anything  un- 
usual is  present.  I  wish  to  emphasize  the  value  of  the  silver  probe  as  a 
diagnostic  aid  in  these  cases  where  the  point  of  discharge  is  upon  the 
face  or  neck ;  in  addition  to  cutting  off  the  sinus  and  emptying  it  in  the 
mouth,  some  attention  must  be  given  to  the  scar.  It  should  be  dissected 
away  from  the  periosteum,  to  which  it  is  usually  attached,  packed,  and 
if  need  be  held  out  in  proper  position  with  a  long  silver  pin  passing 
through  the  scar  tissue,  resting  on  the  surrounding  parts  in  such  a  way 
as  to  hold  the  depressed  part  out  level  with  the  adjacent  tissues.  The 
packing  must  be  kept  up  until  healing  results  from  that  side.  In  all  cases 
of  alveolar  abscesses,  the  offending  teeth — the  teeth  whose  pulp  have  died 
— must  receive  proper  treatment  and  the  canals  thoroughly  filled  if  a  per- 
manent cure  results. 

A  word  should  be  said  here  regarding  molar  teeth.  It  is  sometimes 
seen  that  only  one  root  canal  is  discharging  on  the  gum,  or  perhaps  the 
two  buccal  roots  in  an  upper  molar,  while  the  lingual  root  may  be  dis- 
charging in  the  palate  or  only  presenting  a  tumor-like  swelling  (Fig.  42), 
which  swelling  often  resembles  aneurysms.  There  is  danger  of  mistaking 
the  latter  for  a  forming  abscess  (Fig.  43). 


Fig.  42. 
Acute   abscess   at  buccal   roots   and    chronic  abscess   at   lingual   root.     A,   acute   abscess   cavity; 
b,  pus  cavity  between  bone  and  periosteum;  c,  lip;     d,     tooth;     e,    antrum;     f,    nostril;     g,     molar 
process;  h,  chronic  abscess  discharging  at  i.     (Black.) 


JIncurysm. 

"Aneurvsm  does  not  often  come  under  the  observation  of  the  dentist, 
but  it  does  occur  occasionally  in  the  tract  of  the  posterior  palatine  artery, 
and  in  this  locality  I  have  known  it  to  be  mistaken  for  an  alveolar  abscess 
with  seriou.s  results ;  therefore  never  incise  tumors  on  the  hard  palate 


123 


Fig.  43. 
Aneurysm   of  posterior   palatine  artery. 


(Marshall.) 


without  first  having  given  them  a  careful  examination  to  determine  cer- 
tainly their  nature. 

In  order  to  differentiate  between  an  alveolar  abscess  pointing  on  the 
hard  palate  and  an  aneurysm  of  the  palatine  artery,  make  pressure  on  the 
proximal  side  of  the  artery  from  the  tumor,  and  if  the  tumor  decreases 
in  size  the  indications  point  to  an  aneurysm. 

Again,  place  the  thumb  on  one  side  of  the  tumor  and  the  index 
finger  on  the  other ;  if  there  is  decided  pulsation,  which  not  only  raises 
the  thumb  and  finger,  but  at  the  same  time  perceptibly  separates  the  two, 
this  also  is  an  indication  of  an  aneurysm.  Simple  pulsations  do  not  cer- 
tainly indicate  an  aneurysm.  As  a  tumor  overlying  an  artery  may  give 
sufficient  impulse  to  the  tumor,  so  that  the  result  of  the  heart's  action 
may  be  felt  through  its  substance,  if  the  tumor  be  not  toO'  massive  and 
the  artery  sufficiently  large. 

To  come  to  a  positive  diagnosis,  it  may  be  necessary  to  aspirate  a 
part  of  the  contents  of  the  tumor.  This  may  be  done  by  inserting  the 
needle  of  a  hypodermic  syringe  into  the  tumor  and  then  withdrawing  the 
piston.  If  it  is  an  aneurysm  the  barrel  of  the  syringe  will  contain  arterial 
blood ;  if  an  abscess  it  will  contain  pus.  This  precaution  may  prevent  a 
serious  result,  and  is  advised  in  all  cases  where  there  is  doubt."    (Gilmer). 

Blind  JIb$ce$$. 

The  term  blind  abscess  is  applied  to  those  cases  where  there  is  a  pus 
cavity  about  the  root  apex  with  no  fistulous  or  other  opening  to  the  ex- 
ternal surfaces.     They  are  for  the  most  part  chronic  cases  that  lay  dor- 


124 

tnant,  although  they  may  occasionally  have  periods  of  tenderness.  They 
seem  to  be  very  slowly  progressing,  absorbing  the  bone  little  by  little, 
and  show  no  tendency  to  heal. 

The  pus  is  usually  of  the  laudable  variety,  although  very  liable  to  take 
on  the  septic  thin  serous  or  watery  form,  in  which  case  acute  conditions 
are  set  up,  with  more  rapid  destruction  of  both  bone  and  soft  tissue.  This 
is  the  thing  that  is  so  liable  to  happen  when  the  pulp  chamber  of  a  tooth 
in  this  condition  is  opened  for  the  first  treatment,  and  requires  the  same 
•care  as  is  necessary  in  putrescent  cases,  which  has  already  been  alluded  to. 

treatment  of  Pulpless  Ceetb. 

For  convenience  of  treatment  description  it  seems  advisable  to  divide 
all  these  varieties  of  alveolar  abscess  into  four  classes. 

First — Those  cases  where  the  pulp  canals  are  open  and  have  been 
■exposed  to  the  fluids  of  the  mouth. 

Second — Cases  where  pus  is  discharging  through  a  fistulous  opening 
•on  the  gum. 

Third — Those  cases  where  the  discharge  of  pus  is  at  some  point  dis- 
tant from  the  root  of  the  ofl:ending  tooth. 

Fourth — Blind  abscesses  and  other  dormant  cases. 

Each  class  requires  some  important  modification  in  detail  of  treat- 
ment. In  the  first  class  are  those  cases  where  the  pulp  has  died  as  a  result 
of  exposure  by  caries  and  gone  through  the  stages  of  putrescence  into 
acute  alveolar  abscess  and  perhaps  on  to  the  chronic  form. 

The  management  of  these  cases  is  among  the  most  difficult,  for  like 
many  dormant  cases  they  are  very  prone  to  take  on  active  condition 
when  treatment  begins. 

The  first  step  is  to  remove  all  the  decay  from  the  carious  cavity  and 
pulp  chamber,  opening  up  thoroughly  to  get  free  access.  This  can  usually 
be  accomplished  best  with  spoon  excavators  and  inverted  cone  bur  after 
the  enamel  has  been  chiseled  to  outline.  This  part  can  usually  be  done 
without  the  application  of  the  rubber  dam,  which  will  allow  free  flushing 
with  warm  antiseptic  solution,  washing  out  all  the  debris  as  fast  as  it  is 
loosened  in  excavating,  keeping  in  mind  always  that  it  is  important  that 
nothing  whatever  shall  be  forced  through  the  apical  foramen.  The  next 
step  is  to  apply  the  rubber  dam.  Then  flood  the  cavity  and  chamber  with 
alcohol,  absorbing  with  cotton  and  reapplying  until  all  is  clean  and  dry ; 
flood  again  with  alcohol,  this  time  carefully  working  it  down  into  the 
canal  with  a  smooth  broach  and  then  wash  out  all  debris ;  the  next  step  is 
to  dry  first  with  alcohol  on  cotton,  then  dry  cotton  and  finally  with 
warm  air. 


125 

In  this  dry  warm  condition  a  non-irritating  antiseptic  should  be 
introduced  loosely  on  cotton,  for  which  purpose  oil  of  cloves,  1-2-3,  trik- 
resol,  oil  cloves  and  eucalyptol.  Creosote  has  also  proven  a  good  agent,. 
and  sealed  with  gutta-percha  in  such  a  way  as  not  to  allow  anything  forced 
through  the  foramen.  If  all  keeps  well  this  agent  should  be  allowed  to 
remain  for  four  days. 

At  the  second  sitting  the  dam  is  applied,  the  field  of  operation 
cleansed,  the  canals  reopened,  and  this  time  thoroughly  cleansed  with 
proper  broaches,  so  that  all  walls  of  the  canals  are  free  from  any  clinging 
debris;  alcohol  is  again  used  to  float  out  all  loose  material  and  dry  the 
canals  under  the  same  precaution  as  before.  A  second  sealing  of  the 
same  kind  of  agent  allowed  to  remain  10  days  will  usually  effect  a  cure 
and  prepare  the  tooth  for  root  canal  filling.  In  the  management  of  these 
cases  if  acute  conditions  should  set  in  during  the  progress  of  treatment 
the  patient  should  return  immediately,  the  case  be  reopened  and  treated  as 
an  acute  apical  pericementitis. 

The  second  class  of  cases  includes  both  the  acute  and  chronic  forms.. 
I  have  previously  stated  in  this  chapter  that  the  first  thing  to  do  in 
acute  cases  is  to  get  an  outlet  for  the  forming  pus  and  dismiss  the  case 
until  tenderness  has  subsided.  When  the  patient  returns  for  the  second, 
sitting  and  the  opening,  if  made  on  the  gum,  has  healed,  you  proceed  ex- 
actly as  described  in  Class  i  ;  if  said  opening  still  remains  the  procedure 
is  the  same  as  for  the  ordinary  chronic  case  with  discharge  on  the  gum. 
The  first  step  is  to  clean  the  carious  cavity  if  one  is  present,  and  adjacent 
teeth,  then  apply  the  dam  and  thoroughly  cleanse  and  disinfect  the  field 
of  operation,  particularly  the  tooth  to  be  opened.  The  second  step  is  to 
secure  convenient  access  to  the  chamber  and  canals,  floating  out  all  debris 
with  a  solution  of  bicarbonate  of  soda  in  distilled  water ;  the  canals  should 
then  be  mechanically  cleaned  and  again  washed  with  the  above  solution, 
taking  plenty  of  time  to  wash  out  all  debris  possible  from  the  tubuli.  The 
next  step  is  to  thoroughly  dry  the  canals  and  disinfect  and  deodorize  the 
dentine  with  free  application  of  oil  of  cloves,  using  gentle  heat  to  force 
it  throughout  the  dentine  as  far  as  possible ;  the  object  is  to  cleanse  and 
deodorize  the  dentine  before  any  agent  is  used  that  will  seal  the  tubuli 
filled  with  filth.  The  excess  of  oil  is  removed  by  alcohol  and  the  tooth 
made  ready  for  washing  through  the  fistula,  A  smooth  broach  is  used 
to  make  free  the  opening  through  the  apex.  If  the  approach  to  the  canals 
is  not  so  shaped  as  to  prevent  the  escape  of  solutions  under  pressure  it 
should  be  so  arranged  either  by  the  use  of  gutta-percha  or  cement,  as 
seems  best. 

The  next  step  is  to  force  a  saturated  solution  of  bicarbonate  of  soda 
through  the  canals  and  out  the  fistulous  tract  freely ;  for  this  the  Dunn,, 


126 

or  Farrar  syringe  or  hypodermic  syringe  with  platinum  point  are  well 
adapted ;  over  the  needle  is  placed  a  tapering  rubber  cone,  the  needle  car- 
ried into  the  canal  and  the  cone  held  with  a  strong  pair  of  cotton  pliers 
against  the  prepared  orifice.  Force  enough  is  exerted  on  the  plunger  to 
thoroughly  wash  the  abscess  contents  out  through  the  fistula.  It  is  impor- 
tant to  empty  the  abscess  of  its  pus  before  using  coagulating  agents. 

The  next  step  is  to  dry  the  canal  and  fill  it  with  cotton  soaked  in 
1-2-3  or  95  per  cent  carbolic  acid,  or  phenol-sulphonic  acid,  depending  on 
the  conditions  about  the  apex.  Some  cotton  smeared  with  vaseline  should 
be  placed  around  the  opening  on  the  gum  to  prevent  severe  burning  in 
case  an  excess  of  the  escharotic  escapes.  The  medicine  in  the  canal  is  then 
forced  through,  using  a  piece  of  soft  rubber  and  an  amalgam  plugger 
as  a  plunger.  When  the  agent  appears  at  the  opening  on  the  gum  it  can 
readily  be  detected  by  the  white  appearance  of  the  orifice  of  the  fistula. 

At  this  point  it  has  been  my  practice,  in  bad  cases,  to  hold  a  soft  piece 
of  rubber  over  this  opening  and  again  pump,  thereby  forcing  the  agent  into 
every  corner  of  the  abscess  cavity.  A  mild  dressing  is  sealed  in  the  canal 
for  a  week,  when  if  all  goes  well  the  root  may  be  filled.  In  some  cases 
one  repetition  of  this  treatment  through  the  fistula  may  be  wise.  This 
procedure  will  bring  the  desired  result  in  the  great  majority  of  cases,  but 
for  reasons  which  I  shall  presently  point  out  some  cases  do  not  get  well. 

Occasionally  one  of  these  cases  is  met  with  where  it  is  not  possible 
to  force  anything  through  the  apical  foramen.  When  possible  this  should 
be  opened,  but  this  is  an  operation  that  requires  skill.  A  Downey  or  a 
triangular  piano  wire  broach  are  the  best  instruments  to  use  for  this  pur- 
pose, and  even  with  these  there  is  some  danger  of  breaking  in  the 
foramen.  The  operator  should  work  with  the  idea  of  such  a  possibility 
in  mind  and  proceed  very  slowly,  frequently  withdrawing  the  broach  to 
make  sure  that  it  should  not  bind  and  break.  As  I  have  said,  it  is  desir- 
able to  make  such  an  opening  when  possible,  but  there  are  some  cases 
where  for  various  reasons  this  cannot  be  done.  This  treatment,  then, 
must  be  the  same  as  in  Class  i,  and  in  addition  carbolic  acid,  1-2-3, 
or  phenol-sulphonic  acid  are  carried  into  the  abscess  through  the  fistulous 
opening  with  the  syringe.  In  many  cases  this  will  be  sufficient  (see 
apical  cases).  In  the  third  class  of  cases,  where  the  discharge  is  at  some 
distant  point,  the  treatment  procedure  is  exactly  the  same  as  for  Class  2, 
with  this  exception,  namely,  escharotics  must  not  be  forced  through  long 
distance  of  fistulous  channels.  It  is  safer  practice  to  cut  into  the  channel 
as  near  the  tooth  as  possible  and  treat  the  tooth  as  though  the  discharge 
was  at  this  point.  The  treatment  of  the  rest  of  the  channel  and  the 
external  opening  when  on  the  skin  has  already  been  outlined  in  this  chapter. 

The    fourth    class — blind    abscesses   and   dormant   cases — often    try 


12/ 

men's  souls,  because  of  the  great  liability  of  stirring  up  a  hornet's  nest.  For 
the  most  part  they  are  teeth  whose  pulp  have  died  under  filling  or  from 
traumatic  injuries.  I  read  a  paper  before  the  Chicago  Dental  Society  in 
1889  on  this  subject  which  was  published  in  the  Dental  Reviezv  for  May, 
1900,  from  which  I  quote. 

Every  practitioner  constantly  meets  with  teeth  whose  vitality  has  been 
lost  from  causes  that  we  do  not  understand. 

That  teeth  sometimes  lose  their  vitality  and  give  no  disturbance  for 
years  is  a  fact  well  known  to  all.  Why  this  is  so  cannot  always  be  ac- 
counted for.  Sometimes  the  reasons  can  easily  be  understood.  When  a 
pulp  dies  it  remains  comparatively  harmless  until  it  becomes  infected  by 
micro-organisms — for  without  them  we  will  have  no  putrefaction.  If  a 
tooth  has  no  external  opening  into  the  pulp  canal,  then  micro-organisms 
must  enter — if  they  enter  at  all — through  the  apical  end,  and  their  only 
way  of  getting  there  is  through  the  medium  of  the  circulation.  The  blood 
does  not  normally  contain  micro-organisms,  therefore  it  is  only  by  acci- 
dents such  as  functional  disturbances  of  nutritive  processes,  that  they 
are  enabled  to  live  therein.  When  they  gain  entrance  into  the  system  in 
sufficient  quantities  and  conditions  are  favorable  they  seem  to  immediately 
seek  out  dead  or  dying  matter  in  which  to  grow  and  multiply.  This  ex- 
plains why  many  teeth  containing  dead  pulps,  though  remaining  quiescent 
for  years,  suddenly  develop  acute  conditions  ending  in  acute  and  finally  in 
chronic  alveolar  abscess. 

When  micro-organisms  enter  a  pulp  canal  which  is  filled  with  dead 
matter  we  do  not  always  have  appreciable  physical  disturbances.  In 
many  cases  we  find  foul  smelling  root  canals  when  there  has  been  no  dis- 
turbance, even  though  the  canals  were  closed.  The  understood  reasons  for 
this  are  three : 

First- — The  animal  cells  surrounding  the  part  affected  may  be  suffi- 
ciently active  to  literally  digest  the  micro-organisms  and  hold  in  check 
their  putrefactive  process. 

Second — The  system  may  be  able  to  readily  carry  off  the  products  of 
putrefaction. 

Third — There  may  be  present  in  the  blood  certain  antitoxines  which 
reduce  the  activity  of  the  putrefactive  process  or  neutralize  its  effects. 

These  reasons  explain  why  teeth  containing  imperfect  root  filling 
remain  quiet  for  years  and  other  cases  give  occasional  slight  disturbances, 
which  pass  off  and  remain  quiet  for  another  period ;  then  again  the 
trouble  is  repeated  and  again  ceases,  and  so  on  for  years  and  years. 

Why  is  it,  when  we  open  into  the  pulp  chamber  of  teeth  containing 
dead  putrefactive  matter,  that  we  so  often  start  up  violent  acute  condi- 
tions?   Why  is  it  that  we  sometimes  stir  up  a  veritable  ''hornets'  nest"? 


128 

1  can  only  answer  in  part :  We  disturb  the  balance  of  power  existing  be- 
tween the  putrefactive  process  on  one  side,  and  the  animal  cell,  anti- 
toxines,  or  systemic  conditions,  on  the  other.  We  do  this  in  four  ways : 
By  introducing  fresh  infectious  material,  or  by  forcing  septic  material 
through  into  the  apical  space,  or  by  introducing  some  agent  that  will 
interfere  with  the  local  animal  cell  activity  or  admitting  air. 

There  still  remains  unexplained  many  disturbances  that  follow  the 
opening  of  certain  cases.    There  is  room  for  further  study  on  these  cases. 

In  certain  cases  after  the  death  of  the  pulp,  the  apical  foramen  be- 
comes closed  either  by  deposit  of  cementum  or  by  the  peridental  membrane 
growing  tightly  over  it.  All  that  is  needed  in  treatment  of  these  cases 
is  to  remove  all  dry  material,  moisten  walls  with  a  mild  disinfectant,  dry 
and  fill  immediately. 

In  a  large  number  of  cases  examined  every  case  containing  moisture 
contained  also  pyogenic  germs. 

In  those  cases  where  there  is  no  tenderness  of  tooth  or  tissue  adja- 
cent to  the  apex  of  the  root,  and  no  opening  into  the  pulp  chamber,  after 
adjusting  the  dam,  and  disinfecting  the  tooth  externally  and  surrounding 
tissues,  I  drill  into  the  tooth  almost,  but  not  quite  to  the  pulp  chamber, 
and  seal  therein  a  mild  penetrating  antiseptic  and  let  remain  forty-eight 
hours.  I  now  use  my  trikresol,  oil  of  cloves  and  eucalyptol  mixture — equal 
parts. 

At  the  next  sitting  I  enter  the  pulp  chamber  at  its  horn,  using  a 
small  sterilized  bur,  cutting  in  such  a  way  as  not  to  produce  the  slightest 
pressure  upon  the  contents  of  the  canal ;  then  I  lay  a  piece  of  cotton  con- 
taining some  of  the  above  solution  over  the  opening  partly  to  disinfect 
and  partly  to  absorb  the  liquid  present ;  then  I  carefully  enlarge  the  open  - 
ing  and  draw  ofif  the  contents  of  the  canal,  which  can  be  done  nicely  b}^ 
the  careful  use  of  the  hypodermic  syringe,  and  dry  thoroughly ;  next  I 
lay  a  potent  diffusible  germicide  and  seal ;  care  should  be  taken  not  to 
produce  the  slightest  pressure.  I  allow  this  to  remain  thirty-six  hours, 
when  the  case  is  again  opened,  now  thoroughly — canal  mechanically 
cleaned,  reamed  out  and  dried  thoroughly.  A  non-irritating  disinfectant  is; 
then  introduced  clear  to  the  apex  of  the  root,  and  volatilized  by  heat,  then 
more  introduced,  sealed  and  allowed  to  remain  a  week  or  two  longer. 
At  the  next  sitting  if  canals  are  sweet  and  dry,  and  there  has  been  no. 
conscious  disturbance,  the  roots  are  dried  and  filled. 

In  cases  where  there  is  tenderness  to  pressure,  I  open  immediately,, 
as  before  described,  remove  as  much  moisture  as  possible,  and  lay  into  the 
pulp  chamber  a  potent  germicide,  seal  with  cement  and  drill  a  small 
"vent  hole"  through  the  cement  and  dismiss  the  case  for  twenty-four 
hours,  after  which  I  cleanse  and  dry  the  canal,  as  before  described.     If. 


129 

tenderness  continues  I:use  creosote  and  iodine  for  second  treatment,  car- 
ried well  up  to  the  apex,  seal,  and  allow  to  remain  a  week.  In  anterior 
teeth  care  must  be  taken  not  to  introduce. so  much  of  this  agent  as  to  dis- 
color the  teeth.  I  wish  to  recommend  this  agent  for  cases  of  abscess  in 
syphilitic  patients.  If  tenderness  now  has  disappeared  I  dry  and  fill 
immediately.  If  tenderness  continues,  however,  as  sometimes  occurs,  I 
treat  with  12  per  cent  sulphuric  acid,  forcing  carefully,  a  little  through 
the  apex,  allow  to  remain  twenty-four  hours,  and  follow  with  mild  anti- 
septic and  dismiss  for  two  weeks,  when,  unless  a  large  absorption  exists 
around  the  apex,  the  root  may  be  filled.  The  sulphuric  acid  is  recom- 
mended for  the  double  purpose  of  dissolving  any  slight  uneven,  sharp 
points  of  foreign  deposits  on  the  root  and  destroying  the  so-called 
pyogenic  membrane  existing  about  the  apex. 

Since  following  the  above  plan  I  have  had  very  little  trouble,  but 
when  acute  disturbances  do  arise  the  case  must  be  treated  the  same  as 
indicated  for  Class  i. 

Special  €a$e$. 

After  all  I  have  said  there  yet  remains  many  cases  belonging  to  none 
of  these  classes  and  some  in  each  of  the  four  classes  that  do  not  yield  to 
such  comparatively  simple  measures,  and  sometimes  cause  a  great  deal 
of  anxiety.  For  convenience  of  treatment  description  I  place  them  in 
three  classes. 

First — Those  cases  where  there  •  is  considerable  absorption  of  bone 
around  the  root  apex.  .    - 

Second — Those  cases  where  there  is  some  absorption  of  the  root  end. 

Third — Those  cases  where  there  is  serumal  calculus  deposits  on  the 
apical  end  of  the  root  (Fig.  44). 


Fig.  4i. 
Serumal    calculus    covering 
the    apical    third    of    rout    of 
bicuspid. 


130 

In  all  of  these  cases  there  is  more  or  less  absorption  of  bone  around 
the  root  apex,  which  can  readily  be  detected  by  exploring-  through  the 
sinus  or  by  the  amount  of  discharge  coming  through  the  root  canal  upon 
opening  it  up. 

The  nature  of  the  absorption  can,  to  some  extent,  be  determined  by 
the  nature  of  the  discharge.  If  it  is  thin,  watery,  yellowish,  with  little 
granules  of  bone  mixed  in,  you  can  be  pretty  certain  that  caries  of  bone 
exists.  If  thick,  rich  pus,  simple  absorption.  If  this  yellow  is  streaked 
with  blood,  no  granules,  you  can  count  on  a  roughened  root  end,  which 
should  a  little  later  be  confirmed  by  exploring  through  the  external 
opening. 

I  always  proceed  in  the  management  of  these  cases  exactly  as  I 
would  for  any  chronic  abscess,  namely,  open  up  canals,  drain,  dry,  steril- 
ize, deodorize  the  dentine ;  then  if  there  be  a  fistulous  opening  I  wash 
through  with  the  bicarbonate  of  soda  water,  followed  by  95  per  cent  of  car- 
bolic or  50  per  cent  phenol-sulphonic  acid,  using  the  latter  if  I  am  certain 
of  considerable  bone  absorption.  If  it  has  been  a  bad  pus  case  I  next  seal 
in  10  per  cent  chinosol  for  a  week ;  if  it  is  not  such  a  case,  but  instead 
thin  ichorous  fluid  present,  I  use  paraform,  or  creosote  and  iodine  well 
up  to  the  apex.  If  there  is  no  fistulous  opening  then  I  use  the  same  treat- 
ment, except,  of  course,  I  do  not  wash  through,  but  instead  I  force  a 
little  50  per  cent  phenol-sulphonic  through  the  apex  into  the  space  be- 
yond. When  the  patient  returns  I  always  closely  observe  the  conditions. 
Is  there  any  further  discharge  through  the  fistula  or  down  into  the  canal  ? 
What  is  its  nature?  Is  the  pus  controlled?  Does  hemorrhage  occur  down 
into  the  canal  ?  What  does  the  blood  look  like  ?  Is  it  rich  red,  showing 
that  new  granulations  are  present  and  the  healing  process  nicely  begun  ? 

If  I  am  favorably  impressed  with  the  progress  of  the  case  then  I  seal 
in  a  mixture  of  trikresol,  oil  of  cloves  and  hydronaphthol  and  leave  from 
two  to  four  weeks,  when  I  expect  to  fill  the  root  canal.  If  there  be  a 
little  thin  yellow  serous  fluid  weeping  down  into  the  canal  on  the  second 
visit,  and  especially  if  there  is  a  little  soreness  of  tooth,  I  seal  in  creosote 
and  iodine  carried  well  up  toward  apex,  absorbing  excess  to  prevent  dis- 
coloration. I  will  leave  this  from  two  to  four  weeks,  when  I  will  expect 
to  fill  the  root  canal.  Occasionally  I  treat  one  of  these  cases  a  third  time, 
but  rarely.  At  this  point  I  want  to  say  that  as  a  rule  we  over  treat  teeth, 
treat  them  to  destruction.  I  know  men  who  have  these  cases  running  to 
them  every  other  day  for  weeks  and  months.  Do  you  know  such  treatment 
does  more  harm  than  good  ?  Be  thorough  in  the  detail  of  your  work  and 
use  proper  remedies  and  give  nature  time  in  which  to  make  the  recovery. 
If  the  cases  do  not  progress  favorably  I  fill  the  root  canal  and  proceed  to 
treat  from  the  outside,  for  the  reason  that  I  probably  have  one  of  the 


J3I 

three  conditions  already  described.  For  the  last  three  or  four  years  I 
have  been  studying  these  cases  carefully  and  examining  teeth  removed  by 
our  extracting  specialists,  and  in  85  per  cent  of  the  teeth  removed,  because 
chronic  abscesses  could  not  be  cured,  I  found  the  trouble  v^as  either  root 
roughened  by  absorption  or  deposits  of  calculus. 

It  has  been  my  observation  that  most  regular  practitioners  are  either 
afraid  or  do  not  know  how  to  make  these  explorations.  The  method  I 
follow  is  this :  First,  I  carry  my  index  finger  along  the  gum  over  the  root 
apices  both  lingually  and  labially,  using  sufficient  pressure  to  detect  any 
tender,  soft,  or  springy  spots.  If  the  case  be  long  standing  and  considerable 
amount  of  absorption,  I  will  usually  find  a  spot  over  the  apex  where 
the  bone  has  disappeared  or  has  been  so  absorbed  that  only  a  thin  plate 
remains,  which  will  readily  spring  in,  showing  the  absorption  underneath. 
Next  I  inject  a  little  cocain  solution  into  the  gum  over  the  apex,  and  with 
a  good  strong  lancet  cut  into  it,  making  a  good,  generous  opening,  which 
with  a  little  experience  can  be  done  painlessly;  then  with  proper  shaped 
instruments  I  explore  every  nook  of  that  pocket,  as  well  as  the  end  of  the 
root.  If  I  am  in  doubt  as  to  the  conditions  present,  I  will  pack  with 
antiseptic  gauze  and  leave  twenty-four  hours,  when  if  a  little  care  is 
observed  in  removing  the  gauze  I  can  readily  see  into  the  pocket  and 
know  for  certain  what  has  taken  place  and  proceed  accordingly.  In  cases 
like  Class  i,  the  treatment  is  very  simple.  If  it  fails  to  heal 
readily  from  treatment  as  described  through  the  root  canal,  which 
frequently  occurs,  I  fill  root  canal  and  then  make  the  generous  opening 
as  before  mentioned ;  next  pack  the  pocket  with  cotton  saturated  in  cocain 
solution,  being  careful  to  so  place  loose  cotton  around  the  opening. as  to 
absorb  any  cocain  that  may  exude. 

I  leave  the  cotton  pack  in  the  pocket  for  about  five  minutes,  when  I 
proceed  to  thoroughly  curette  the  pocket,  scraping  all  rough  or  dead  bone 
(rather  take  a  little  more  than  necessary  than  not  enough).  While 
scraping  I  flood  with  cassia  water,  keeping  it  clean,  so  I  can  see  exactly 
what  I  am  doing.  If  the  case  should  belong  to  the  second  or  third  class 
I  proceed  in  exactly  the  same  manner,  and  in  addition  I  scrape  off  the 
serumal  calculus  and  smooth  up  the  root  apex.  In  the  second  class  of 
cases  I  resect  the  root  end,  cutting  away  all  that  portion  that  is  roughened 
by  absorption  and  at  the  same  time  make  the  end  of  the  root  round  and 
smooth  (see  Fig.  69).  This  completes  the  surgical  part  of  the  work. 
There  only  remains  the  after  treatment,  which  is  very  simple,  and  consists 
packing  with  plain  gauze  saturated  with  25  per  cent  phenol-sulphonic 
acid,  leave  for  48  hours,  remove  pack,  wash  with  cassia  water  and  pack 
with  antiseptic  gauze,  preferably  aristol;  repeat  every  third  day  for  a 
couple  of  weeks,  when  the  case  should  be  well.     The  important  point  in 


132 

the  treatment  is  to  keep  antiseptic  and  compel  healing  from  bottom, 
keeping  sinus  open  until  pocket  is  quite  nearly  filled  in.  Of  course  each 
treatment  will  require  less  and  less  gauze,  and  at  no  time  after  the  opera- 
tion should  there  be  pus  present ;  if  there  is  then  you  have  not  thoroughly 
used  your  curette.  I  know  that  many  of  you  will  think  that  this  method  of 
treatment  is  severe  and  difhcult,  but  I  want  to  assure  you  that  such  is 
not  the  case,  and  the  pain  that  I  cause  by  such  an  operation  is  not  at  all 
severe.  In  treating  several  hundred  of  these  cases  I  have  only  used  a  gen- 
eral anesthetic  twice.  To  those  that  have  not  tried  this  method  I  ask  them 
to  try  it  and  see  if  it  does  not  prove  helpful  and  a  tooth  saver.  I  recom- 
mend it  most  cordially  over  the  old  method  of  treating  through  root  canal 
for  months  and  then  losing  the  tooth  in  the  end. 


CHAPTER  XIII. 


Infection,  Instrument  Sterilisation,  ana  Germicides. 

Infection.     Carrying   Infection.     A    Germicidal  Solution.    Broach  Sterilization.    In- 
strumental   Sterilization.      Germicides ;  Some  Dental  Uses. 


The  subject  of  infection  and  instrument  sterilization  bears  such  an 
important  relation  to  the  treatment  of  pulpless  teeth  that  I  decide  to  in- 
clude in  this  volume  parts  of  two  articles  written  by  myself,  the  first  on 
infection,  published  in  The  Dental  Summary  for  June,  1903,  and  the  latter 
published  in  The  Dental  Review  for  May,  1903. 

Tttfectioiu 

To  infect  means  to  introduce  into  the  tissues  a  poison  or  virus  which 
has  the  power  of  invading  and  multiplying,  thereby  setting  up  serious 
disturbances  of  physical  well-being.  This  disturbance  may  be  local  only, 
or  it  may  affect  the  whole  organism  as  well ;  indeed,  it  is  certain  if  the 
local  infection  is  violent,  that  the  system  as  a  whole  will  suffer. 

This  is  a  subject  upon  which  much  has  been  written  of  late  years, 
and  yet  I  am  of  the  opinion  that  the  profession  does  not  appreciate  its  im- 
portance. I  have  formed  this  opinion  as  a  result  of  many  years'  experi- 
ence in  directing  the  treatment  of  cases  in  a  large  public  infirmary,  as 
well  as  in  private  practice,  to  both  of  which  many  serious  cases  are  sent 
by  regular  practitioners.  I  think  it  is  true  that  most  dentists  have  learned 
to  recognize  syphilitic  cases,  and  are  fully  aware  of  the  danger  of  in- 
fecting themselves  and  others  from  them ;  also  I  believe  that  a  large  ma- 
jority understand  the  precautions  that  are  necessary  in  order  to  avoid 
doing  so,  and  is  it  not  a  fact  that  a  majority  of  dentists  regard  this  disease 
as  the  only  source  of  danger?  I  am  certain  they  practice  as  if  they  do. 
This  article  is  written  to  point  out  some  of  the  most  common  ways  in 
which  we  may  infect  pulps,  gums  or  other  tissues  of  the  mouth,  and  to 
suggest  a  method  to  avoid  doing  so.  Infection  depends  upon  certain 
things,  among  which  are : 

First — The  nature  and  condition  of  germs  infecting,  with  reference 
to  virulency. 

Second — The  condition  of  the  part  through  which  infection  occurs, 
with  reference  to  location,  cellular  elements  of  the  tissues  as  well  as  its 
chemistry. 

Third — The  condition  of  the  system  as  a  whole,  with  reference  to 
■nutrition,  including  where  the  physiological  functions  are  disturbed,  in- 
fection takes  place  more  readily.  - 


134 

All  agree  that  the  mouth  is  usually  a  "hot-bed"  of  micro-organic 
life;  almost  every  known  variety  there  abound.  Were  is  not  for  the  fact 
that  the  saliva  is  normally  antiseptic  to  a  slight  degree,  and  is  constantly 
moving,  we  would  have  more  difficulty  in  getting  open  wounds  in  the 
mouth  to  heal.  In  this  sense  nature  favors  healing.  When  tissue  be- 
comes injured,  abraded  or  loses  its  vital  force,  and  infectious  material  is 
confined  within  or  retained  upon  it  for  a  period  of  time,  of  course  the 
liability  of  infection  increases ;  for  these  reasons  I  want  to  call  attention 
to  the  advisability  of  thoroughly  cleansing  surfaces  through  which  hypo- 
dermic needles,  lancets  or  exploring  needles  are  to  be  introduced.  Sur- 
geons quite  universally  take  these  precautions,  but  how  many  dentists  do? 
How  many  are  in  the  habit  of  forcing  needles  or  lancets  through  surfaces 
that  are  covered  with  all  sorts  of  infectious  material?  When  pain,  sore- 
ness and  sloughing  follow,  we  wonder  why.  Before  scaling  teeth,  how 
many  take  the  precaution  to  first  rid  the  mouth  of  all  putrefactive  material 
lying  upon  the  gum  margins  around  the  necks  of  the  teeth  ? 

When  you  think  of  it,  how  important  it  is.  How  many  take  the  same 
precautions  before  placing  the  rubber  dam  clamp  around  the  necks  of 
teeth?  In  the  majority  of  cases  that  instrument  injures  the  gum,  and 
with  rubber  dam,  retains  the  infectious  material  in  contact  with  it  for  the 
length  of  time  required  for  the  operation.  The  same  is  true  of  rubber 
dam  when  applied  alone  or  with  ligatures,  but  to  a  less  degree.  The  dan- 
ger is  even  greater  when  wedges  or  separators  are  used.  A  rule,  then,  I 
would  like  to  advance  is :  Always  cleanse  the  teeth  and  gums,  especially 
around  the  gum  margin,  of  all  particles  of  food  and  putrefactive  debris 
before  beginning  any  operation.  The  most  particular  attention  should 
be  given  the  teeth  in  the  immediate  field  of  operation.  For  this  purpose 
I  first  use  a  ball  of  cotton  in  the  pliers,  saturated  with  dioxygen  and  carry- 
ing a  little  fine  powder.  With  this  I  scrub  the  teeth  and  gums ;  then  I 
use  the  compression  air  atomizer  and  wash  out  the  interproximate  spaces 
with  an  antiseptic  solution.  I  thoroughly  flood  the  mouth,  depending  as 
much  on  the  mechanical  cleansing  as  on  the  antiseptic  wash. 

With  this  method  you  can  feel  reasonably  certain  that  you  have  re- 
duced the  liability  of  infection  to  a  minimum,  and  it  only  required  a 
minute.  In  operating  on  teeth,  especially  where  the  pulp  is  involved,  I 
take  the  additional  precaution  of  washing  off  the  teeth  with  alcohol  after 
the  rubber  dam  is  in  position. 

earrying  Infection. 

In  scaling  teeth  it  is  important  to  keep  the  instrument  in  a  good 
germicidal  solution,  and  do  not  carry  scalers  from  a  pus  pocket  on  one 
tooth  to  another  tooth  without  first  wiping  off  and  dropping  it  into  the 


135 

solution.  I  am  thoroughly  satisfied  that  many  carry  infection  from  such 
pockets  to  the  healthy  peridental  membrane  or  other  teeth  by  carelessness 
in  this  regard. 

H  eermicidal  Solution. 

As  a  germicidal  solution  I  use  sublamine,  one  in  two  hundred,  and 
for  the  purpose  of  wiping  off  the  scales  I  use  small  squares  of  chinosol 
gauze.  I  attribute  much  of  my  success  in  treating  "pyorrhea  alveolaris"" 
to  these  precautions. 

My  brother,  I  want  to  interrogate  you  again ;  you  see  I  am  after  you. 
How  often  do  you  take  a  nerve  broach  from  a  putrescent  canal  and  carry 
it  up  into  a  pulp  you  have  devitalized,  or  a  clean  canal,  without  sterilizing 
it?  Take  a  case,  we  will  say  an  upper  first  molar  with  three  root  canals, 
one  putrescent  or  filled  with  pus,  the  others  clean,  perhaps  made  so  by 
you;  now,  honestly,  don't  you  frequently  take  your  broach  from  the 
putrescent  canal  and  carry  it  into  others  without  first  sterilizing  it  ?  Don't 
you  sometimes  take  a  broach  from  a  pus-filled  canal  and  carry  it  into  the 
canal  in  a  neighboring  tooth  where  you  are  removing  a  non-infected  pulp  ? 
How  often  do  you  wind  cotton  on  a  broach  with  unclean  fingers,  and 
carry  this  into  the  canals?  Perhaps  you  don't,  but  the  majority  of  prac- 
titioners do.  Then  they  wonder  why  teeth  become  sore  after  the  pulp  is 
removed.  Many  think  they  sterilize  their  broach  when  they  dip  it  into 
oil  of  cloves,  cassia,  or  such  agents,  and  leave  it  there  a  few  seconds,  but 
I  assure  you  they  don't. 

Broad)  Sterilization. 

For  the  purpose  of  getting  some  fairly  accurate  information  regard- 
ing broach  sterilization,  I  undertook  a  series  of  experiments.  The  method 
was  this :  I  took  small  pieces  of  broaches,  both  steel  iridio-platinum,  and 
sterilized  them  by  heat  to  redness.  When  cool,  which  only  took  a  few 
seconds,  they  were  carried  into  foul  root  canals,  pus  pockets,  abscesses 
and  ulcers,  then  dipped  into  various  agents  and  left  various  lengths  of 
time,  after  which  they  were  removed,  washed,  and  dropped  into  tubes 
containing  beef  bouillon  culture  media,  and  readings  made  from  time  to 
time  for  96  hours.  Test  tubes  were  made  from  each  case  used,  and 
microscopic  comparisons  frequently  made.  The  length  of  time  broaches 
were  kept  in  the  medicament  was  gradually  increased  until  no  cultures 
were  obtained.  The  table  of  results  follows,  and  is  self-explanatory: 
Time  required  to  sterilise  broach.  Time  required  to  sterilize  broach. 

Medicament.  Min.  Medicament.  Min. 

Oil  of  Cloves 37     Trikresol 5 

"       Cassia    35      Creolin ^ 5 

"       Sassafras   40     Sublamine,  i  in  200 2 


136 

Time  Required  to  Sterilise  Broach.         Time  Required  to  Sterilise  Broach. 
Medicament,  Min.  Medicament.  Min. 

Oil  of  Peppermint  40      Chinosol,  10  per  cent  solution.  .      i 

Cade 25      Dioxygen 25 

"       Birch  tar  ....  ..  ?.  ....  .   25      Bichloride  of  Mercury,  i  in  500.   10 

"       Wintergreen 60      Campho-phenique    ..........  .  .   20 

"       Cajeput 30       Hydronaphthol,  20  per  cent  in 

"       Cinnamon    40  alcohol    20 

"       Eucalyptus   45      Beta-naphthol,    20   per   cent    in 

Carbolic  acid 20  alcohol 32 

Creosote,  Beechwood 25 

These  tables  only  prove  so  far  as  small  broaches  are  concerned,  but 
not  for  larger  instruments,  although  they  will  readily  show  what  agents 
would  be  likely  to  be  most  effective  for  such.  They  show  the  absurdity 
of  attempting  to  sterilize  an  unclean  broach  by  simply  dipping  it  in  any 
of  the  essential  oils,  or  in  fact  any  but  a  very  few  agents.  Chinosol,  ten 
per  cent,  proved  most  efficacious,  but  cannot  be  used  for  steel,  as  it  cor- 
rodes it,  but  for  other  metals  it  is  very  valuable.  Corrosive  sublimate 
has  the  same  objections.  Carbolic  acid,  trikresol,  and  the  like,  are  too 
irritant  to  be  carried  into  soft  tissue  by  instruments,  and  unless  you 
wanted  their  special  escharotic  effects  in  a  root  canal,  you  would  scarcely 
like  to  dip  broaches  in  them.  From  my  experience  I  recommend  the  use 
of  sublamine,  i  to  200,  for  steel  instruments ;  chinosol,  10  per  cent,  for 
those  of  other  metals. 

Instrument  Sterilization. 

The  most  practical  method  of  sterilizing  instruments  after  each  case 
is  by  boiling  water  containing  a  slight  amount  of  sodii  bicarbonatis,  for 
which  purpose  I  have  had  made  a  small  sterilizer  consisting  of  a  zinc 
box  with  a  tight  closing  lid  four  inches  wide,  eight  inches  long  and 
seven  inches  high,  into  which  a  removable  tray  is  fitted  and  arranged  so 
the  instruments  will  stand  upright.  This  box  rests  upon  a  standard 
and  has  a  gas  jet  underneath.  I  had  it  made  by  a  tinsmith  at  an  expense 
of  $7,  and  I  think  it  fills  the  requirements  better  than  any  other.  It  does 
not  heat  the  room  to  any  extent,  is  sightly  and  very  convenient,  and 
inexpensive  to  run.  If  instruments  are  boiled  in  it  for  15  minutes  you 
can  be  reasonably  sure  they  are  well  sterilized.  The  instruments  we  need 
to  be  most  careful  about  sterilizing  are  clamps,  separators,  files,  reamers, 
trimmers,  scalers,  lancets,  needles,  broaches.  The  simplest,  easiest  and 
surest  way  of  doing  so  is  by  boiling.  Before  boiling  they  should  be  well 
scrubbed  with  soap  and  water.  Try  the  precaution  herein  suggested  and 
you  will  be  delighted — at  least  they  are  very  helpful  to  me. 


137 
Germicides:  Some  Dental  Uses. 

A  germicide  is  an  agent  that  destroys  germ  life  and  their  spores. 
It  is  a  term  of  recent  origin,  and  is  derived  from  the  Latin,  german  =^ 
germ  +  csedere  =  to  kill ;  literally,  to  kill  germs.  In  dental  literature 
the  term  is  quite  generally  used  to  mean  pus-germ  destroyers.  It  is 
only  since  the  germ  theory  of  putrefaction  became  understood  that  this 
word,  germicide,  has  taken  on  its  present  significance.  The  recent 
studies  into  the  phenomena  of  life,  physiological  chemistry  and  phar- 
macology, bid  fair  to  completely  change  our  present  system  of  thera- 
peutics. We  are  beginning  to  see  that  our  present  accepted  so-called 
rational  system  of  treating  pathological  conditions  is  indeed  most  irra- 
tional and  empirical.  Not  much  longer  will  it  do  to  treat  certain  condi- 
tions with  certain  remedies  simply  because  our  fathers  did,  or  even  be- 
cause we  have  observed  in  a  previous  case  good  results  followed  like 
treatment  we  must  now  know  the  reason  why. 

There  is  no  department  of  medicine  (using  the  term  medicine  to 
include  our  and  all  other  specialties)  that  is  so  unscientific  as  that  of 
therapeutics.  Enough  work  has  been  done  to  show  conclusively  that  all 
remedial  agents,  of  whatever  nature,  that  have  any  action  upon  the 
physical  organism  do  so  by  means  of  the  chemical  relation  which  they 
bear  to  the  organ,  tissue,  or  pathological  condition  treated.  They  act 
by  means  of  a  certain  selective  chemical  affinity.  Certain  organs  and 
tissues  under  certain  conditions  attract  and  appropriate  certain  medicinal 
agents,  when  so  placed  as  to  be  accessible.  Scientists  have  for  several 
years  recognized  what  is  known  as  the  chemotactic  property  of  cell  life — 
the  attracting  and  repelling  force  which  one  cell  or  set  of  cells  exert 
toward  another.  They  look  upon  all  organized  life  as  a  multiplication 
of  cells,  each  having  a  specific  function  or  functions,  and  each  related 
to  the  other  in  a  chemical  way.  The  whole  physical  life  process  is  a 
chemical  one.  The  laws  which  govern  the  selection  and  preparation  of 
food  digestion,  assimilation  and  throwing  off  waste  material  are  chemi- 
cal. This  is  not  only  true  of  the  whole  organism  we  call  man,  but  is 
equally  true  in  the  micro-organic  world.  Furthermore,  it  also  holds  true 
in  the  relation  of  the  former  to  the  latter.  The  baneful  influences  of 
micro-organic  life  upon  higher  organisms  is  exerted  through  chemical 
processes.  The  solution  of  animal  cell  tissue,  plastic  exudate  in  wounds, 
and  formation  of  pus  are  all  chemical  processes  in  which  micro-organic 
life  plays  the  important  role. 

Tonight  I  want  to  present  the  thought  of  destroying  the  micro- 
organic  life  and  their  baneful   influences  in  animal  tissue,  by  chemical 


*Read  before  the  Chicago  Dental   Society,  Jan.   6,  1903. 


138 

The  disassociation  theory  of  Arrhenius,  which  had  many  able  ex- 
ponents, and  which  has  been  developed  to  a  marvelous  point  in  recent 
years,  throws  much  light  on  this  problem.  The  theory  explained  in  a 
few  words  is  this :  When  certain  organic  and  inorganic  acids  or  salts 
are  carried  into  solution,  either  in  the  body  or  outside,  they  split  up  into 
ions — the  negatively  charged  ones  called  anions,  and  the  positive  ones 
called  kations.  The  action  of  such  agents,  therefore,  depends  upon  the 
nature  of  its  ions.  This  fact  was  brought  out  through  a  marvelously 
interesting  series  of  experiments  of  Professor  Jacques  Loeb,  formerly  of 
the  University  of  Chicago,  but  now  of  the  University  of  California.  No 
longer  do  we  deal  in  the  main  with  the  molecules  of  which  a  substance 
is  composed,  but  with  the  ions  into  which  it  breaks  up.  "We  know,  for 
example,  that  we  can  substitute  at  will  sodium  iodide  for  potassium 
iodide,  in  order  to  produce  certain  therapeutic  effects.  These  salts  are 
alike  in  that  they  both  yield  I-ions ;  they  differ  in  that  the  former  yield 
sodium  ions  and  the  latter  potassium  ions.  Any  similarity  manifested  in 
the  therapeutic  effects  of  these  two  salts  is  determined  by  the  similarity 
of  their  iodine  ions.  But  we  know  that  the  potassium  iodide  is  much 
more  depressant  than  the  sodium  salts.  This  is  due  to  the  direct  poison- 
ous effects  of  the  potassium  ions  upon  muscle  and  nerves,  an  effect  not 
exhibited  by  sodium  ions."* 

This  same  principle  holds  true  regarding  the  germicidal  action  of 
drugs.  They  are  efficient  in  proportion  to  the  number  of  ions  they  con- 
tain. In  mercury  compounds,  for  example,  it  is  not  the  amount  of  mer- 
cury in  the  salt,  but  the  number  of  mercury  ions  that  determines  the 
efficiency.  Example :  A  given  per  cent  solution  of  HgClg  in  alcohol ; 
a  solvent  in  which  slight  disassociation  occurs  is  less  potent  than 
aqueous  solutions. 

What  is  needed  now  is  an  extended  study  of  the  exact  action  of 
various  ions.  We  must  learn  what  kind  of  ions  produce  a  certain  result. 
Then  the  chemist  will  have  little  difficulty  in  furnishing  us  with  sub- 
stances capable  of  disassociating  into  such  ions  as  we  need  for  a 
given  purpose.  This  disassociation  may  often  be  brought  about  by  first 
undergoing  some  change  or  changes  within  the  tissue,  and  then  going 
into  solution  and  disassociation  by  means  of  the  solvent  in  the  tissues. 
With  these  ideas  in  mind,  the  chem_ists  have  been  at  work  with  no  end  of 
new  remedies  as  a  result,  many  of  which  are  useless  because  they  have 
not  been  sufficiently  tested,  but  rushed  into  the  market  to  precede  some 
other  fellow.  A  few  are  excellent,  and  to  some  of  which  I  want  to  call 
your  attention.  While  these  studies  have  been  going  on  the  physiologist 
has  been  at  work,  and  shown  us  that  germicides  act  upon  the  protoplasm 

*Dr.  Martin  H.   Fisher,   American  Journal  of  Physiology,   1901. 


139 

of  the  proteid  molecule  in  this  chemical  way.  Proteids  are  the  most  im- 
portant substances  occurring  in  animal  and  vegetable  organisms.  None  of 
the  phenomena  characteristic  of  life  occur  without  their  presence ;  they 
are  invariably  and  constantly  constituents  of  protoplasm.  They  are 
highly  complex  and  uncrystallizable  (for  the  most  part)  compounds  of 
carbon  hydrogen,  oxygen,  nitrogen  and  sulphur.  The  difference  between 
the  proteid  molecule  of  higher  forms  of  multi-cellular  life  and  that  of  the 
purely  vegetative  forms  has  not  yet  been  well  made  out. 

An  enormous  amount  of  work  is  necessary  to  bring  out  the  exact 
relation  and  the  exact  composition  of  each.  The  inorganic  salts,  espe- 
cially those  of  the  heavy  metals,  such  as  mercury,  iron,  copper,  lead, 
zinc,  etc.,  act  by  forming  insoluble  compounds  with  protoplasm  of  bac- 
teria. They  do  not  penetrate  deeply  into  the  cell,  and  their  action  is, 
therefore,  uncertain  and  usually  very  slight,  HgCl^  being  the  most  po- 
tent of  the  group,  because  of  its  special  toxic  property,  but  its  efficacy 
is  greatly  lessened  if  there  are  other  proteids  present,  especially  in  the 
solutions  which  can  be  safely  used  on  account  of  their  toxicity. 

The  fatty  acid  series,  the  coal  tar  derivatives,  phenol,  naphthol,  re- 
sorcin,  salol,  thymol,  guaiacol,  cresol,  etc.,  and  to  this  group  we  may  add 
beechwood  creosote,  salicylic  acid,  etc.,  also  act  by  coagulating  the  proto- 
plasm to  a  greater  or  less  degree ;  but  with  these  agents  the  coagulum 
is  quite  soluble,  and  so  the  agents,  if  kept  in  contact,  penetrate  deeper, 
and  to  that  extent  are  fairly  germicidal,  especially  to  germs  that  have  an 
easily  permeable  cell  wall,  and  this  is  especially  true  of  carbolic  acid, 
which  is  more  or  less  volatile. 

It  must  be  understood  that  none  of  these  agents  acts  in  a  chemical 
way,  but  simply  by  coagulation,  which  is  a  molecular  process.  None 
of  these  agents  enters  into  chemic  combinations  with  the  proteid.  While 
the  salts  of  the  metals  produce  insoluble  precipitates,  and  thus  prevent 
greater  penetration,  so  that  their  germicidal  power  depends  upon  the 
degree  of  precipitability  of  the  different  proteids,  the  aromatic  series, 
to  which  belong  the  essential  oils,  can  scarcely  be  called  germicides.  They 
act  by  simple  irritation  ;  in  no  sense  chemic. 

The  oxidizers  and  reducers  all  tend  to  produce  chemic  changes  in 
micro-organisms.  They  all  act  rapidly,  and  are  rapidly  decomposed  by 
all  organic  matter.  Hydrogen  dioxide  is  perhaps  the  best  known  of  this 
class  of  agents.  The  rapid  effervescence  is  evidence  of  its  rapid  action. 
The  failure  to  get  good  germicidal  results  from  this  class  lies  in  the  dif- 
ficulty to  bring  each  germ  into  contact  with  the  agents  long  enough  to  be 
destroyed.  This  difficulty  is  increased  a  hundred-fold  when  used  within 
the  tissues  of  the  body,  for  the  reason  that  they  are  equally  active  towards 
the  organic  matter  of  the  tissues. 


140 

There  is  a  fact  which  is  often  lost  sight  of  in  considering  this  sub- 
ject which  is  of  vast  importance,  and  that  is  this :  In  the  appHcation  of 
germicides  to  suppurations  we  must  consider  the  tissue  in  which  the 
suppurative  process  is  going  on.  Nearly  all  these  old  agents  act  more 
forcefully  against  the  cells  of  the  tissue  than  against  the  micro-organisms 
therein. 

Many,  and  indeed,  most  germicides  are  so  coagulant,  or  otherwise 
destructive  of  the  cell  tissue,  as  to  make  their  use  in  concentrated  form 
dangerous,  and,  indeed,  most  of  them  possess  general  toxic  or  other  dele- 
terious properties  after  absorption  which  often  endanger  life.  There- 
fore, in  the  practical  applications  of  germicides,  we  must  always  consider : 

1.  Action  on  the  system. 

2.  Action  on  the  tissues  of  the  part. 

3.  Action  on  the  germs  in  the  part. 

And  this  brings  us  to  two  important  points  for  consideration,  namely, 
( I )  the  stimulating  influence  that  certain  agents  exert  toward  the  normal 
cell  elements  of  the  part;  (2)  the  antiseptic  influence  that  certain  agents 
exert  upon  the  whole  organism,  through  the  medium  of  the  blood  stream. 

When  suppurative  micro-organisms  get  into  the  injured  tissue  of  a 
part,  by  any  means,  there  occur  some  interesting  things.  The  injured 
tissue  will  soon  be  seen  to  be  literally  filled  with  reparative  cells,  cells 
which  are  carrying  the  necessary  elements  of  repair  to  the  injury,  and 
carrying  away  the  useless,  discarded  elements  to  be  excreted  and  thrown 
ofif  from  the  body.  Mixed  into  this  veritable  beehive  will  be  seen  these 
micro-organisms,  and  if  conditions  are  favorable  they  will  grow  and 
multiply  rapidly.  A  "battle  royal"  occurs  between  these  invading  ene- 
mies and  the  reparative  cells ;  sometimes  one  is  victorious  and  sometimes 
the  other,  depending  upon  (i)  the  condition  and  nature  of  the  micro- 
organisms; (2)  the  condition  of  the  cells  of  the  part;  (3)  the  condition 
of  the  general  system.  There  is  some  interesting  detail  in  this  connection, 
but  time  forbids  further  elucidation.  It  must,  however,  be  clear  to 
everyone,  and  this  is  the  point  I  am  trying  to  bring  out,  that  favorable 
resolution  may  sometimes  be  brought  about  by  directing  our  attention 
to  any  or  all  of  these  three  things ;  ( i )  We  may  destroy  or  inhibit  the 
growth  of  the  micro-organism  direct.  (2)  We  may  stimulate  the  cells 
of  the  part  to  increased  activity  and  they  in  turn  destroy,  break  down, 
these  enemies.  (3)  We  may  act  upon  the  whole  organism  with  refer- 
ence to  stimulated  circulation,  assimilation  and  excretion,  or  increase 
the  blood  antisepsis,  or  any  one  or  all  of  which,  within  certain  limitation, 
would  be  equally  potent  so  far  as  results  are  concerned.  This  explains 
why  we  have  long  been  using  certain  agents  which  are  not,  strictly 
speaking,  germicides,  with  good  results.     Iodoform,  for  example.    I  want 


141 

to  emphasize,  if  I  may,  the  need  of  attention  to  all  three  of  these  things-, 
if  we  would  be  very  successful  in  treating  serious  suppurations.  In  every 
serious  infection  we  should  always  look  to  the  nature  of  the  micro-organ- 
ism infecting ;  the  condition  of  tissues  of  the  part ;  and  the  condition  of  the 
whole  system,  with  reference  to  nutrition,  including  excretion  and  circu- 
lation, and  also  the  condition  of  the  nervous  system,  before  we  determine 
what  agent  or  agents  we  shall  use. 

The  methods  employed  for  determining  the  germicidal  power  of 
agents  are  many,  all  of  which  are  imperfect,  and  whenever  you  read  a 
statement  of  the  germicidal  power  of  any  agent  you  must  know  the  na- 
ture of  the  germs  used  in  the  test ;  how  they  were  previously  grown ; 
how  they  were  tested ;  in  what  media  they  were  grown  before  and  after, 
and  what  was  the  method  of  subjecting  them  to  the  agent,  before  you 
can  have  any  idea  of  its  value.  All  tests  only  prove  so  far  as  these  things 
are  known,  and  do  not  prove  anything  beyond  that;  because  an  agent 
proves  germicidal  toward  a  particular  germ  or  mixture  of  germs,  under 
certain  conditions,  using  any  method,  only  proves  so  far  as  that  series, 
but  does  not  prove  anything  so  far  as  other  germs  or  methods  of  using 
are  concerned ;  therefore  all  experimental  tests  are  only  relatively  valu- 
able, and  only  useful  for  comparison,  and  beyond  that  prove  nothing. 

The  literature  of  the  medical  and  dental  professions  is  full  of  con- 
flicting statements  regarding  the  potency  of  various  agents,  classed  as 
germicides,  the  reasons  for  which  are  explained  by  the  foregoing  state- 
ment. In  most  cases  I  have  succeeded  in  duplicating  their  experiments 
when  the  above  conditions  have  all  been  stated.  In  not  a  few  instances  I 
have  clearly  demonstrated  their  faulty  technique.  I  have  tried  almost 
every  published  method  at  some  time  or  other  in  the  last  five  years,  and 
have  concluded  that  the  method  suggested  by  myself  in  1899  is  open  to 
the  least  objection,  and  yields  results  most  nearly  uniform,  and  yet  I  do 
not  wish  to  convey  the  idea  that  this  method  will  any  way  accurately  tell 
what  will  occur  when  applied  to  actual  practice  in  treating  suppurations 
in  the  living  tissue ;  but  when  these  results  are  applied  to  such  treatment, 
and  there  studied,  and  modified  to  meet  condition,  good  results  will  fol- 
low. Until  the  chemistry  of  the  proteid  molecule  under  its  various  patho- 
logical changes  is  more  clearly  made  out  this  is  the  best  we  can  do. 
Pharmacology,  the  study  of  the  action  of  remedies  when  practically  ap- 
plied, must  at  present  be  our  main  reliance.  Science  and  experience  must 
go  hand  in  hand. 

In  making  experimental  tests,  it  is  essential  that  the  agent  used  be 
pure  and  reliable ;  that  the  germs  be  exposed  to  it  in  equal  numbers  under 
the  same  conditions ;  that  they  be  at  their  maximum  height  of  virulency, 
should  be  pure  cultures,  and  that  they  be  cultivated  in  media  and  tern- 


142 

perature  most  favorable  to  their  growth.  In  the  experiments  from 
which  the  following  tables  were  made  up  the  following  method  was  used ; 
Organisms  were  grown  in  bouillon  made  from  lean  beef  (not  beef  extract) 
in  the  usual  manner,  and  neutralized  with  sodium  hydrate  (not  sodium 
bicarbonate).  In  series  D  and  E  it  was  made  slightly  alkaline.  The 
germs  were  grown  and  distributed  throughout  the  media  in  equal  num- 
bers, as  shown  by  microscopic  examination.  The  germs  were  transferred 
in  loopfuls  to  small  squares  (a  centimeter)  of  filter  paper,  which  was 
previously  sterilized  and  kept  in  a  petri  dish ;  there  they  were  allowed  to 
dry;  then  on  to  this  was  carried  by  means  of  the  loop  sufficient  of  the 
medicament  to  completely  cover  the  filter  paper,  and  left  for  various 
lengths  of  time,  when  each  square  was  washed,  so  as  to  remove  the 
medicament,  and  planted  in  fresh  tubes  of  culture  media,  and  placed  in 
an  incubator,  at  37°  Centigrade.  Readings  were  taken  from  time  to  time 
for  a  week.  The  germicidal  power  of  the  medicaments  is  here  determined 
by  the  time  necessary  to  expose  germs  to  it,  and,  as  you  will  see,  a  great 
difference  appears.  You  will  notice  that  some  agents  were  used  in  full 
strength  and  others  in  per  cent  solutions,  according  as  they  could  be  used 
in  practice. 

In  all  of  these  series  of  experiments  I  began  by  exposing  the  germ 
to  the  medicament  five  minutes,  and  worked  each  way  from  that  point, 
according  as  growth  appeared  or  not.  When  doubt  existed,  inoculations 
were  made  in  fresh  media  and  in  animals — guinea  pigs  and  young  rabbits 
mostly. 

In  these  tables  only  fiinal  results  are  given.  They  are  made  up  after 
many  repetitions. 

$erlc$  D. 

Germ  used,  staphylococcus  pyogenes  aureus.  Grown  and  plated  out 
from  abscess  pus. 

Per  Cent  Time  Required, 

Agent.  Solution.  Minutes. 

Oil  cassia Full  strength 55 

Oil  cinnamon Full  strength 55 

Oil  cloves Full  strength 55 

Oil  cajeput Full  strength 50 

Oil  eucalyptus Full  strength 60 

Oil  wintergreen Full  strength 60 

Oil  peppermint Full  strength 55 

Oil  cade .  ..Full  strength 50 

Oil  birch  tar Full  strength 30 

Oil  pennyroyal Full  strength 42 


143 

Per  Cent  Time  Required, 

Agent.  Solution.  Minutes. 

Carbolic  acid 95  per  cent 30 

Creosote,  B.  W Full  strength 40 

Campho-phenique   Full  strength 40 

Guaiacol   Full  strength 40 

Thymol Alkaline,  Saturate  solution 30 

Thiocol   Alcoholic,  Saturate  solution 30 

Aspirin   Alcoholic,  9  per  cent  solution 22 

Bichloride  mercury 1-1,000  20 

Phecene Sat.  solution 12 

Creolin    Full  strength 3  • 

Trikresol   Full  strength 5 

Sublamine i  in  250 c 

Xresamin    Full  strength 5 

Phenol   sulphonic Full  strength 5 

Pormalin   Full  strength 3 

Chinosol   10  per  cent    solution i 

Series  €. 

Germ,    streptococcus    pyogenes    in    virulent    form    from    periosteal 
abscess. 

Per  Cent  Time  Required, 

Agent.  Solution.  Minutes. 

Oil  cassia Full  strength 60 

•Oil  cinnamon Full  strength 60 

Oil  cloves Full  strength 60 

Oil  cajeput Full  strength 55 

Oil  eucalyptus Full  strength 60 

Oil  wintergreen Full  strength 60 

Oil  peppermint Full  strength 55 

Oil  cade Full  strength 40 

Oil  birch  tar Full  strength 30 

Oil  pennyroyal Full  strength 35 

Carbolic  acid 95  per  cent 30 

Creosote,  B.  W Full  strength 40 

Campho-phenique    Full  strength 60 

Thymol Alkaline,  Saturate  solution 40 

Thiocol   Alcoholic,  Saturate  solution. 32 

Aspirin   "'. Alcohol,  9  per  cent  solution 22 

Mercury  bichloride i  in  1,000 15 

Phecene Sat.  solution 10 


144 

Per  Cent  Time  Required, 

Agent.  Solution.  ^Alinutes. 

Creolin    Full  strength 5 

Trikresol   Full  strength 5 

Sublamine   i   in  250 .        5 

Kresamin    Full  strength 5 

Formalin    Full  strength 3 

Chinosol    10  per  cent i 

Scries  T. 

Germ,  Proteus  bacillus. 

Per  Cent  Time  Required, 

Agent.  Solution.  Minutes. 

Oil  cassia Full  strength. 55 

Oil  cinnamon Full  strength 40 

Oil  cloves Full  strength 45 

Oil  cajeput .Full  strength 50 

Oil  eucalyptus .Full  strength 50 

Oil  wintergreen Full  strength 55 

Oil  peppermint Full  strength 50 

Oil  cade Full  strength 40 

Oil  birch  tar Full  strength 30 

CarboHc  acid 95  per  cent 20 

Creosote   Full  strength „ 15     ■ 

Thymol Liquor,  potass.,  Sat.  solution 20 

Thiocol  Alcoholic,  Sat.  solution 10 

Aspirin   Alcoholic,  9  per  cent  solution 18 

Naphtha  eucalyptus Alcoholic,  Sat.  solution 10 

Chinosol   10  per  cent  solution i 

Mercury  bichloride 1-1,000 22 

Phecene Sat.  solution 10 

Creolin    Full  strength 8 

Trikresol   Full  strength 5 

Formalin   Full  strength i 

Tribromo  phenol Alcoholic,  Sat.  solution 8 

Trichlorphenol    Alcoholic,  Sat.  solution 8 

Sit'm  6. 

Germ  used,  mixed  pus  culture. 

Per  Cent  Time  Required, 

Agent.  Solution.  Minutes. 

Oil  cassia Full  strength 40 

Oil  cinnamon Full  strength 40 

Oil  cloves Full  strength 40 


145 

Per  Cent  Time  Required, 

Agent.  Solution.  Minutes. 

Oil  cajeput Full  strength 45 

Oil  eucalyptus Full  strength 40 

Oil  wintergreen Full  strength 60 

Oil  peppermint Full  strength 50 

Oil  cade Full  strength 25 

Oil  birch  tar Full  strength 20 

Oil  pennyroyal Full  strength 45 

Carbolic  acid Full  strength 30 

Creosote,  B.  W Full  strength 30 

Campho-phenique   Full  strength 40 

Mercury  bichloride 1-1,000   25 

Creolin Full  strength 5 

Trikresol   Full  strength 5 

Sublamine i  in  250 3 

Kresamin   Full  strength 5 

Formalin   Full  strength ,2 

Chinosol   10  per  cent i 

Phenol   sulphonic Full  strength 5 

Tribromo  phenol Alcoholic,  Sat.  solution 10 

Trichlorphenol   Alcoholic,  Sat.  solution 8 

Series  1). 

Bacillus  pyoscyaneus.     Isolated  from  pus. 

Per  Cent  Time  Required, 

Agent.  .  Solution.  Minutes. 

Oil  cassia Full  strength 38 

Oil  wintergreen Full  strength 45 

Oil  cinnamon Full  strength 40 

Oil  cloves Full  strength 40 

Oil  cajeput Full  strength 45 

Oil  eucalyptus Full  strength 40 

Oil  wintergreen Full  strength 40 

Oil  peppermint Full  strength 40 

Oil  pennyroyal Full  strength 40 

Carbolic  acid 95  per  cent  full  strength 10 

Creosote,  B.  W Full  strength 20 

Oil  sassafras Full  strength 40 

Creolin    Full  strength 5 

Trikresol   Full  strength 2 

Formalin   Full  strength i 


146 

Per  Cent  Time  Required, 

Agent.  Solution.  Minutes. 

Sublamine   i  in  250 2 

Bicliloride  of  mercury i  in  1,000 5 

Kresamin    .  .  . ". Full  strength 3 

Phenol    sulphonic Full  strength 2 

Chinosol    10  per  cent  strength i 

Campho-phenique    Full  strength 10 

Eugenol P\ill  strength 30 

Permanganate  of  potash   .  10  per  cent  strength 30 


Scries  T. 

Germ, 

bacillus 

prodi 

igiosus. 

Per  Cent. 

Agent. 

Solution. ' 

Time  Required, 
Minutes. 

Oil  cassia Full  strength 35 

Oil  cinnamon Full  strength 35 

Oil  cloves Full  strength    35 

Eugenol Full  strength 32 

Oil  cajeput Full  strength 40 

Oil   eucalyptus Full  strength 40 

Oil  wintergreen Full  strength 40 

Oil  peppermint Full  strength 30 

Oil  pennyroyal Full  strength 35 

Carbolic  acid Full  strength 15 

Creosote Full  strength 18 

Trikresol   Full  strength •. . 2 

Kresamin Full  strength 2 

Bichloride  of  mercury 1-1,000 5 

Sublamine   1-500   2 

Permanganate  of  potash.  . .  10  per  cent 25 

Phenol  sulphonic Full  strength 5 

Chinosol    10  per  cent i 

These  tables  only  show  the  time  required  to  completely  destroy  all 
life.  Nearly  all  agents  showed  marked  restraint  in  less  time.  ]\Iany  of 
the  germs  exposed  to  the  essential  oils  fifteen,  and,  indeed,  thirty  minutes, 
grew  as  quickly  and  as  luxuriantly  as  the  controller. 

You  will  note  the  excellent  showing  made  by  the  following  agents : 
Formalin,  sublamine,  phenol  sulphonic  acid,  trikresol,  creolin,  kresamin, 
phecene,  chinosol. 

The  application  of  germicides  as  such  to  treatment  of  oral  diseases 
is  quite  limited.    It  is  only  in  violent,  acute,  chronic,  necrotic  suppurations ; 


147 

in  syphilitic  ulcers,  eczema,  etc.,  and  in  each  case  the  selection  of  the 
particular  agent  will  be  determined  by  the  conditions  present.  They  are 
also  of  value  as  hand  and  instrument  disinfectors. 

Formalin  is  a  colorless  liquid,  resembling  water  in  appearance,  and 
is  a  40  per  cent  solution  of  formaldehyde  gas.  It  is  probably  the  most 
potent  germicide  that  can  be  used.  Its  dental  uses  are  limited!,  because 
of  its  extreme  irritating  property.  I  have  used  it  in  old  chronic  abscesses, 
but  in  nearly  every  instance  severe  pain  and  swelling  resulted,  which  has 
caused  me  to  abandon  it  except  in  weak  dilutions  in  such  agents  as 
creosote. 

Paraform,  a  new  solid  polymer,  has  recently  been  recommended. 
There  is  a  class  of  cases  where  it  is  of  value,  if  used  with  care.  I  refer 
to  old  blind  abscesses  on  the  roots  of  teeth,  containing  small  tortuous 
canals.  This  agent  readily  gives  up  formaldehyde  gas,  which  is  very 
penetrating.  It  should  only  be  placed  in  the  large  entrance  to  the  pulp 
chamber,  and  not  down  in  the  root  canals,  and  even  then  it  stirs  up  some 
irritation.  In  coming  to  this  conclusion,  I  have  lost  some  teeth  from  its 
use,  but  if  you  are  careful  and  use  it  as  stated  you  will  find  it  of  excel- 
lent value.  Recentl}^  some  practitioners  have  recommended  it  as  a  com- 
ponent part  of  root  fillings.  I  am  somewhat  skeptical  of  the  result.  In 
old  chronic  cases,  where  there  is  little  or  no  discharge  of  pus,  but  instead 
a  thin  ichorous  fluid  comes  weeping  down  into  the  canal,  cases  that  are 
not  causing  any  great  amount  of  pain,  but  sore  and  constantly  annoying, 
in  all  such  cases  I  get  good  results  from  this  drug.  It  always  increases 
the  soreness  and  inflammation,  which  soon  terminates  in  resolution. 
Perhaps  the  most  valuable  use  we  can  make  of  this  agent  is  as  a  disin- 
fectant for  foul  rooms,  for  operating  rooms,  where  serious  surgical  cases 
are  attended  to ;  for  instruments,  especially  those  used  on  syphilitic 
cases. 

Paraform  has  recently  been  put  upon  the  market  in  tablet  form, 
especially  designed  for  use  in  Schering's  sterilizer.  It  is  both  efifective 
and  convenient. 

Bichloride  of  mercury  as  a  germicide  was  first  brought  to  the  atten- 
tion of  the  medical  profession  by  Koch,  since  which  time  its  use  has 
become  almost  universal.  It  is  a  potent  germicide  toward  all  germs  that 
have  a  very  permeable  cell  wall.  It  is  very  corrosive,  producing  insoluble 
coagulum,  and  therefore  limiting  its  power.  Its  most  serious  objections 
are  its  irritant  and  toxic  properties.  In  dental  practice  its  use  has  been 
quite  generally  abandoned,  except  as  a  hand  disinfectant,  and  on  gauze 
for  packing  suppurating  antrum ;  also  in  syphilitic  cases. 

Sublamine.  Ethylenediamine  sulphate  of  mercury.  A  new  agent, 
recommended  as  a  substitute  for  bichloride  of  mercury. 


148 

Ethylenediamine  is  an  organic  base,  with  a  chemical  formula  of 
C  H,  —  N  Ho 

I 
C  H2  —  N  Ho 

It  is  a  clear,  colorless  liquid  of  alkaline  reaction,  and  gives  off  the 
odor  of  ammonia.  This  substance  is  used  in  connection  with  several 
coagulant  germicides,  for  the  purpose  of  reducing  their  irritant  property 
and  increasing  their  penetrative  power.  Sublamine  comes  to  us  in  solid 
form,  and  is  freely  soluble  in  water.  I  have  been  using  it  in  the  strength 
of  I  in  500,  and  find  it  but  very  slightly  irritating.  It  is  a  non-coagulant, 
and  will  penetrate  much  more  deeply  than  bichloride.  In  all  the  tests 
it  has  proven  much  more  efficacious  than  bichloride,  and  certainly  is 
much  more  agreeable  to  use.  I  can  most  heartily  recommend  it  for  ster- 
ilizing hands,  washing  indolent  ulcers,  flushing  the  antrum,  for  washing 
through  chronic  abscesses,  sterilizing  the  skin  before  operations.  For  all 
these  purposes  I  have  been  using  it  in  my  private  practice,  as  well  as  in 
the  public  infirmary.  It  is  a  chemical  germicide,  carrying  pus  into 
solution. 

Phenol  sulphonic  acid  is  a  light  reddish-colored  liquid,  made  by  conv 
bining  equal  parts  of  sulphuric  and  carbolic  acid.  It  is  not  so  coagulant 
or  irritating  as  either  of  the  substances  from  which  it  is  made.  It  can  be 
used  in  full  strength  for  burning  through  old  chronic  abscesses,  and  is 
especially  recommended  where  cases  are  of  long-standing,  with  more  or 
less  of  bone  absorption  around  the  apex  of  the  root.  It  is  valuable  to 
enlarge  root  canals,  and  to  burn  out  the  socket  after  a  badly  abscessed 
tooth  is  removed.  Of  course,  it  must  always  be  used  with  caution.  A  50 
per  cent  solution  is  especially  recommended  to  aid  in  the  exfoliation  of 
necrosed  bone ;  it  will  also  disintegrate  and  dissolve  small  pieces  of  tooth 
and  necrosed  bone  that  may  be  left  after  burring  or  curetting  about  the 
jaws.  I  use  it  on  gauze  for  the  first  packing  after  such  operations,  espe- 
cially in  the  antrum.  Weaker  solutions  may  be  used  to  wash  out  after 
surgical  operations  on  the  jaws.  I  have  come  to  look  upon  it  as  one  of 
my  most  valuable  agents. 

Trikresol ;  another  product  from  Schering's  chemical  laboratory.  Its 
composition  is  as  follows :  Ortho-cresol,  35  per  cent;  metacresol,  40  per 
cent,  and  para-cresol,  40  per  cent.  It  is  a  clear  liquid  pungent  odor, 
resembling  phenol ;  turns  slightly  red  on  exposure  to  strong  sunlight.  Is 
soluble  in  2  per  cent  water,  but  freely  in  alcohol  and  oils.  It  is  a  splen- 
did germicide,  as  shown  by  these  experiments,  and  an  agreeable  prepara- 
tion to  use.  I  have  been  using  it  about  four  yeais,  and  now  find  I  am 
using  it  in  almost  every  condition  where  I  formerly  used  carbolic  acid  or 
creosote.     It  is  not  so  escharotic  as  carbolic  acid ;  will  penetrate  much 


149 

deeper  into  vegetable  cells,  and  will  destroy  spores.  Two  per  cent  solu- 
tion is  antiseptic.  I  recommend  it  to  burn  out  old  abscesses;  as  a  dress- 
ing in  root  canals  in  acute  apical  pericementitis ;  in  putrescent  pulp ;  to 
relieve  odontalgia,  applied  warm  or  almost  hot.  It  penetrates  the  den- 
tine as  readily  as  the  essential  oils,  but  does  not  discolor  it.  A  little  (not 
an  excess)  is  useful  as  a  dressing  after  pulps  are  extirpated,  before  filling 
root  canals.  To  keep  scalers  and  such  instruments  sterile  while  using,  I 
keep  them  in  a  ten  per  cent  solution  in  alcohol  and  water.  It  is  an  excel- 
lent agent,  used  full  strength,  as  a  first  treatment  in  pus  pockets  about  the 
roots  of  teeth. 

Kresamin  is  the  <name  given  to  a  combination  of  ethylenediamine  and 
trikresol,  containing  equal  parts  of  each.  It  is  a  reddish-colored,  phenol- 
like liquid;  has  an  agreeable  odor,  and  is  very  slightly  irritant.  It  is 
practically  non-caustic,  and  but  feebly  coagulant.  It  is  powerfully  germi- 
cidal, equal  to  i  in  500  bichloride  of  mercury.  I  have  been  using  it 
lately  in  the  clinic,  with  most  flattering  results.  I  am  satisfied  if  used  in 
acute  or  recent  chronic  abscesses  it  will  be  of  value.  I  wash  through 
such  abscesses  freely  with  it.  I  have  passed  some  around  among  a  few 
of  my  dental  friends,  and  they  are  all  delighted  with  the  results  they  are 
getting  with  it.  It  is  freely  soluble,  and  may  be  used  as  an  antiseptic  in 
dilute  solutions.  It  is  a  chemical  disinfectant.  When  brought  in  contact 
with  thick  pus,  kresamin  seems  to  immediately  dissolve  it,  and  turn  it  a 
dark  brown  color.  In  apical  pericementitis  from  any  cause,  it  seems  to  be 
of  great  value ;  also  applied  to  inflamed  pulps  it  has  an  immediate  quieting 
influence.  In  all  inflammations  accompanied  with  pus  form.ation  I  am 
sure  of  its  efBcacy. 

Chinosol  has  a  chemical  formula  of  CgHgNo  KSO^,  and  is  prepared 
by  the  action  of  sulphate  of  potassium  on  chinoline,  a  basic  coal  tar  de- 
rivative. It  occurs  in  the  form  of  a  crystalline  yellow  powder,  possessing  a 
very  slight  odor,  and  pungent  coal  tar  taste.  It  is  freely  soluble  in  water, 
but  insoluble  in  ether  or  alcohol.  It  is  a  chemical  germicide.  When 
brought  in  contact  with  pus  in  the  slightly  alkaline  fluid  of  the  tissues, 
it  is  readily  broken  up  into  oxychlorine,  and  it  is  this  that  is  so  power- 
fully germicidal.  So  far  as  my  knowledge  goes,  it  is  the  most  potent 
germicide,  so  far  as  pus  germs  are  concerned,  of  any  agent  at  our  com- 
mand. I  began  using  and  recommending  it  for  the  eradication  of  pus  in 
1893,  since  which  time  it  is  my  main  standby.  It  has  two  slight  objec- 
tions, namely,  it  corrodes  steel  instruments  (not  others),  and  has  a  slight 
tendency  to  darken  teeth ;  such  discoloration  is  very  readily  removed  with 
any  oxygen  bleacher.  Being  almost  devoid  of  odor,  it  is  not  a  very  good 
deodorant  for  foul-smelling  dentine,  but  as  a  pus-destroyer  it  certainly 
has  no  equal. 


150 

It  is  practically  non-irritating;  is  wholly  non-coagulant  and  non- 
caustic.  I  use  it  in  2  per  cent  solution  for  washing  out  bad  pus  pockets, 
abscesses  in  antrum,  and  alveolus.  I  use  a  ten  per  cent  solution  in 
chronic,  foul,  violent  abscesses,  and  all  other  violent  suppurations.  It  is 
used  only  for  the  purpose  of  getting  rid  of  pus.  When  you  need  to 
burn  out  necrotic  tissue,  it  is  not  recommended.  It  is  wholly  non-toxic, 
and  can  be  used  ad  Uhitiun  in  these  solutions.  Injected  into  a  forming 
abscess,  boil  or  carbuncle,  it  will  immediately  get  rid  of  the  pus.  In  any 
case  of  violent  pus  infection,  where  there  is  danger  of  serious  results,  this 
is  the  most  efficient  agent ;  especially  in  streptococcus  infection,  which  is 
active,  you  can  use  no  better  drug.  Chinosol  gauze,  absorbent  cotton,  and 
soap  may  be  had  in  the  market.  If  you  have  an  abscessed  antrum,  where 
pus  is  rapidly  being  formed,  try  chinosol  irrigation,  and  chinosol  gauze, 
pack  to  control  it,  and  you  will  be  delighted. 

I  have  shown  you  these  cultures  and  tests,  and  called  your  special 
attention  to  these  agents,  not  because  they  are  the  only  good  ones,  but 
rather  because  I  have  had  the  most  practical  experience  with  them.  I  have 
used  all  of  them  on  many  hundred  cases  in  th'e  infirmary,  and  have  the 
written  history  of  treatments  to  corroborate  all  I  have  said.  Some  of 
you  I  know  have  tried  some  or  all  of  these  agents ;  others  have  not  tried 
any.  I  simply  want  to  make  a  plea  for  their  value  over  the  remedies  you 
are  using.    Won't  you  try  them? 


CHAPTER  XIV. 

matiddement  of  Discolcrea  teetb* 

General    Considerations.      Causes    of   Tooth    Discoloration.      Methods    of   Tooth 

Bleaching.     Agents.     The  Direct  Oxygen  Alethod.     Method  of  Using. 

Ethereal    Solution.      Sodium    Dioxide.      Chlorin  Method. 


General  Considerations. 

There  is  no  subject  in  the  whole  range  of  dental  science  that  needs 
to  be  more  thoroughly  understood  than  the  management  of  discolored 
teeth.  The  operator  must  always  keep  in  mind  the  possibility  of  pulpless 
teeth  becoming  discolored  and  particularly  is  it  important  to  avoid  such 
results  in  the  anterior  part  of  the  mouth.  We  should  not  use  rusty 
instruments  or  medicines  that  tend  to  discolor  the  dentine  and  in  a 
general  way  keep  our  cases  clean  and  free  from  outside  contamination. 

The  tendency  of  all  pulpless  teeth  is  to  change  their  normal  color. 
Not  all  pulpless  teeth  discolor  perceptibly,  but  they  all  lose  their  normal 
translucency.  In  many  teeth  this  change  is  not  sufficient  to  attract  atten- 
tion, but  upon  very  close  examination  it  will  be  seen.  It  must  not  be  taken 
as  a  positive  proof  that  a  tooth  has  lost  its  pulp  when  it  is  a  slightly  dif- 
ferent shade  in  color  from  its  neighbor ;  indeed,  teeth  of  different  denomi- 
nations in  the  same  mouth  differ  in  this  respect. 

The  cuspid  teeth  are  ahvays  darker  than  the  incisors  or  bicuspids,  and 
in  not  a  few  instances  one  central  Avill  differ  from  the  other  a  shade  or 
more.  I  have  had  a  few  cases  where  discoloration  was  marked,  and  yet 
upon  opening  the  chambers  the  pulps  were  found  vital  and  healthy.  I 
think  it  is  an  established  fact  that  under  certain  inflammatory  influences 
pigmentation  of  the  dentine  may  result,  and  yet  the  pulp  return  to  health, 
although  the  instances  are  rare. 

Causes  of  tootb  Discoloratiom 

For  convenience  of  study  I  like  to  group  the  causes  of  tooth  discolora- 
tion under  three  heads. 

First.  Discoloration  following  the  death  of  the  pulp  where  there  is  no 
pulp  exposure. 

Second.  Discolorations  following  death  of  pulp  and  subsequent 
exposure  of  the  chamber  to  the  secretions  of  the  mouth. 

Third.  Special  discolorations  from  the  staining  influences  of 
medicines,  amalgam  fillings,  etc. 

In  the  first  class  the  source  of  pigmentation  is  in  the  decomposition  of 
the  pulp  tissue,  and  such  other  secretions  as  may  enter  the  canals  from 


1=^2 


the  blood  stream  and  surrounding  tissues  entering  through  the  foramen. 
In  the  simplest  form  it  is  the  direct  result  of  severe  inflammations  of  the 
pulp,  which  result  in  the  destruction  of  that  organ.  These  inflammations 
may  be  the  result  of  irritation  of  fillings,  arsenic,  traumatic  injuries  of  all 
sorts,  in  which  the  vascular  supply  is  the  prominent  factor. 

The  various  changes  produced  in  the  pulp  by  such  forms  of  irritation 
have  been  fully  explained  in  Chapter  X,  and  all  I  wish  to  do  here  is  to  offer 
such  explanations  as  are  at  hand  as  to  the  process  by  which  such  resulting 
discolorations  are  produced. 

In  such  cases  the  discoloration  is  directly  due  to  the  breaking  down  of 
the  corpuscular  elements  of  the  blood  in  which  the  hemoglobin  is  set  free 
from  the  red  corpuscles,  and  passes  into  solutions  which  readily  infiltrate 
the  tubuli  of  the  dentin,  giving  the  tooth  a  decidedly  pinkish  hue.  Every 
operator  can  call  to  mind  many  such  cases,  following  arsenical  application, 
where  the  pink  cast  can  readily  be  seen,  especially  when  the  eye  is  aided  by 
transillumination.  Teeth  so  discolored  readily  change  unless  the  operator 
interferes,  from  pink  to  yellow,  which  gradually  grows  darker  until  brown 
and  finally  become  a  grayish  black. 

The  violence  of  the  pulpitis  seems  to  have  something  to  do  with  the 
degree  and  rapidity  of  the  discoloration  and  hence,  from  this  sta>"idpoint, 
it  is  inadvisable  to  apply  arsenic  to  an  already  inflamed  pulp.  Kirk 
says :  "In  passing  through  its  cycle  of  color  changes  hemoglobin  under- 
goes several  alterations  in  composition,  during  which  a  number  of  definite 
compounds  are  formed,  each  having  marked  chromogenic  features.  Of 
these  composition  products  methemoglobin  (brownish  red),  hemin 
(bluish  black),  hematin  (dark  brown  or  bluish  black),  and  hematodin 
(orange),  are  best  known." 

It  is  doubtless  true  that  this  accounts  for  those  discolorations  resulting 
from  inflammation  and  death  of  the  pulp  before  putrefactive  decompo- 
sition sets  in,  but,  when  that  process  has  begun,  there  are  other  elements 
to  consider  and,  before  we  can  understand  them,  it  is  necessary  to  take  into 
consideration  the  chemistry  involved.  The  chemistry  of  the  proteid  mole- 
cules of  all  albuminous  material,  including  pulp  tissue,  is  not  very  well 
understood,  but  enough  is  known  to  furnish  a  rational  explanation  for 
tooth  discoloration  resulting  from  the  decomposition  of  the  pulp  tissue. 
The  important  elements  in  the  composition  of  the  proteid  substance  of  the 
pulp  tissue  are  carbon,  oxygen,  hydrogen,  nitrogen,  phosphorus  and  sul- 
phur; in  the  putrefactive  decomposition  of  this  tissue  certain  chemical 
compounds  are  formed,  among  which  are  carbon  dioxid,  ammonia,  hydro- 
gen sulphid,  and  water,  none  of  which  in  themselves  cause  the  discolora- 
tion, but  when  hydrogen  sulphide  is  brought  in  contact  with  hemoglobin 
in  solution  in  the  presence  of  oxygen  sulfo-methemoglobin  is  formed, 


153 

resulting  in  a  certain  amount  of  ferrous  sulphide  and  other  iron  salts 
being  formed,  and  it  is  these  that  furnish  the  green,  brown,  and  black 
colors  when  forced  into  the  tubuli — at  least  they  play  a  very  important 
part  in  tooth  discoloration.  In  the  second  group  of  cases  there  are  added 
factors  both  in  the  causation  and  modifying  influences  upon  the  resulting 
discoloration  which  must  be  considered. 

When  a  pulp  dies  from  exposure  and  putrefactive  decomposition  occurs 
in  the  presence  of  such  oral  secretions  as  may  enter  through  such  exposure, 
the  process  is  modified  greatly,  and  the  character  of  the  discoloration  like- 
wise changed. 

The  breaking  down  of  the  tissue,  the  changes  in  the  vascular  elements 
and  subsequent  putrefaction,  are  more  rapid  in  these  cases,  and  a  ready 
way  of  escape  for  forming  gases  and  salts  makes  deep  discoloration  less 
liable,  and  then  the  oral  secretions  may  bring  some  substances  that  will 
enter  the  tubuli  and  thus  modify  the  character  of  the  color  and  make  suc- 
cessful bleaching  difficult.  In  the  third  group  of  cases  are  included  those 
discolorations  resulting  from  metallic  and  medicine  stains,  and  are  among 
the  most  difficult  to  handle. 

Metallic  salts  are  very  apt  to  stain  the  tooth  substance  by  their  chemi- 
cal reaction  with  the  hydrogen  sulphid  with  which  dentine  is  saturated  in 
putrefactive  cases.  Iron  from  rusty  instruments,  particularly  when 
brought  in  contact  with  iodine  and  copper,  producing  those  greenish  stains, 
which  after  a  tim.e  become  black,  that  we  often  see  from  the  use  of  copper 
alloy  fillings,  posts,  dowels,  screws,  etc.  These  stains  are  difficult  to 
remove. 

Silver  and  mercury  stains  are  usually  black  and  are  the  direct  result 
of  certain  combinations  of  metals  in  dental  alloys,  in  which  the  silver  and 
mercury  are  so  acted  upon  by  the  secretions  of  the  mouth,  that  slight 
amount  of  salts  are  formed  which,  in  time,  stain  the  dentine.  The  nitrate 
of  silver,  sometimes  used  as  an  obtundant,  always  stains  the  dentin  black. 
These  are  easily  removed. 

methods  of  tc^otb  Bkacbind. 

The  process  of  tooth  bleaching  is  a  chemical  problem  in  which  there 
must  be  a  reaction  between  the  agents  used  and  the  staining  or  discoloring 
substance. 

The  chemical  reaction  must  result  in  the  formation  of  such  new  com- 
pounds with  the  coloring  substance  as  are  either  freely  soluble  and  can 
be  washed  out,  or  colorless  compounds  which  are  stable  and  not  liable  to 
change  back  to  their  original  state  or  into  some  other  coloring  substance. 

If  the  chemistry  of  the  coloring  substance  could  always  be  understood 
it  would  be  a  comparatively  easy  matter  to  find  a  substance  that  would 
combine  with  it  in  such  a  way  as  to  bring  about  the  desired  result,  but  at 


154 

the  present  time  we  find  many  teeth  discolored  by  some  agent  the  nature 
of  which  we  do  not  know,  and,  therefore,  some  cases  do  not  yield  to  any 
bleaching  method  at  our  command. 

Agents, 

There  are  two  general  groups  of  agents  used  at  the  present  time  for 
tooth  bleaching. 

First.  Oxydizing  agents,  substances  which  give  ofif  oxygen  in  a 
nascent  condition. 

Second.  Reducing  agents,  substances  which  have  a  strong  affinity 
for  oxygen. 

In  the  first  group,  there  are  two  distinct  classes,  namely:  Direct 
oxydizers,  such  as  hydrogen,  dioxid  and  sodium  dioxide,  and  indirect 
oxydizers,  such  as  chlorin^  bromin. 

In  the  group  of  reducing  agents  only  one  substance  has  been  used 
to  any  extent,  and  that  is  sulphurous  oxid. 

In  the  use  olall  bleaching  agents  there  are  certain  things  which  are 
fundamental,  and  success  with  any  of  them  will  depend  on  how  thoroughly 
the  detail  is  carried  out. 

First.  All  metallic  fillings  in  the  tooth  to  be  bleached  must  be  removed. 

Second.  The  rubber  dam  must  be  securely  applied  to  the  discolored 
tooth  only. 

Third.     The  apical  third  of  the  root  must  be  filled  with  gutta-percha. 

Fourth.  The  pulp  chamber  must  be  completely  opened,  and  as  much 
dentin  as  can  easily  be  removed  without  endangering  the  integrity  of  the 
tooth  should  be  cut  away.  The  chamber  should  be  enlarged  to  include  the 
thin  points  where  the  horns  of  the  pulp  were. 

Fifth.  The  shape  of  the  cavity  in  the  teeth  must  be  such  as  to  permit 
of  rapid  closing  so  as  to  prevent  the  escape  of  the  gases  as  much  as  possible. 
If  it  is  not  so  naturally,  then  it  must  be  made  so  by  using  gutta-percha. 

Sixth.  No  metal  instruments  should  be  used  in  the  work  with  agents 
that  will  readily  corrode  them,  and  thus  produce  a  new  staining  substance. 

Seventh.  The  bleaching  process  should  be  continued  until  the  dis- 
colored tooth  is  a  shade  or  two  lighter  than  its  neighbors,  for  the  tendency 
of  all  cases  is  to  go  back  a  little. 

Eighth.  When  the  bleaching  process  is  finished  the  chambers  must  be 
lined  by  some  white  substance  upon  which  permanent  filling  can  be  built. 

Ninth.  Teeth  that  are  checked  badly  or  whose  dentine  is  exposed  to 
the  fluids  of  the  mouth  are  very  liable  to  discolor  again. 

Tenth.  Teeth  that 'have  been  bleached  should  be  temporarily  filled  for 
three  months  in  order  to  a;scertam  rf  the  result  is  permanent  before  the 
trouble  and  expense  of  permanent  operations  are  undertaken. 


155 
tbe  Direct  Oxygen  method. 

In  bleaching  discolored  teeth  with  hydrogen  dioxid,  two  solutions  are 
used,  namely,  a  25  per  cent  aqueous,  and  a  25  per  cent  ethereal  solution. 

The  methods  are  slightly  different;  the  ordinary  hydrogen  dioxid 
obtainable  in  the  market  is  a  3  per  cent  aqueous  solution,  which  is  not 
strong  enough  for  our  purpose  as  a  bleacher. 

Its  strength  can  be  increased  by  slowly  and  carefully  evaporating 

some  of  the  water ;  this  is  best  accomplished  as  follows :     Select  a  small 

porcelain  evaporating  dish  which  must  be  smooth  and  free  from  flaws ; 

into  this  pour  two  ounces  of  hydrogen  dioxid,  then  float  it  on  a  water  bath, 

cover  with  loose  paper  to  protect  from  dust,  and  slowly  heat  until  the  two 

ounces  are  reduced  to  one-quarter  of  an  ounce,  which  usually  takes  about 

45  minutes ;  this  will  give  about  a  25  per  cent  solution,  which  is  the  most 

desirable  strength,  and  will  keep  in'  a  colored  bottle  loosely  corked  for 

several  davs. 

method  of  Using. 

When  the  chamber  and  cavity  are  ready  to  receive  this  bleaching  agent 
it  is  applied  on  a  loose  roll  of  cotton  into  the  chamber,  and  also  the  outside 
of  the  crown  is  moistened,  then  a  draught  of  warm  air  is  directed  on  the' 
tooth,  w^hich  will  assist  in  the  free  liberation  of  oxygen.  The  agent  is 
renewed  every  five  minutes  or  so  for  about  four  applications,  between  each 
of  which  I  dry  the  tooth  with  warm  air.  In  the  majority  of  cases  half  an 
hour  will  be  all  the  time  that  is  required  for  the  bleaching  of  recently  dis- 
colored cases,  particularly  teeth  of  a  pinkish  hue. 

When  the  bleaching  is  completed  the  dentin  should  be  thoroughly 
washed  with  warm  distilled  water.  A  convenient  little  rubber  bag  for 
catching  the  water  used  in  flushing  can  be  made  of  rubber  dam  with  the 
aid  of  rubber  cement.  This  bag  or  pocket  can  be  so  shaped  as  to  admit 
of  passing  up  on  the  lingual  of  the  teeth,  and  held  by  the  dam  holder  and 
the  overflow  carried  away  with  the  saliva  ejector.  It  is  sometimes  neces- 
sary to  repeat  the  bleaching  operation  once  or  twice  a  few  days  apart. 

In  my  hands  this  has  proven  a  very  successful  method. 

etbmal  Solution. 

In  bleaching  with  the  25  per  cent  ethereal  solution  of  hydrogen  dioxid 
the  procedure  is  exactly  the  same,  with  this  additian,  that  in  very  stubborn 
cases  it  may-be  sealed  in  the  chamber  for  24  hours. 

The  best  results  seem  to  be  attained  from  this  solution  when  it  is 
rendered  slightly  al4<aline  by  the  addition  of  a  little  sodium  dioxid. 

^/        -  Sodium  Dioxid  naa  O2* 

Sodium  di&xid  is  another  compound  that  readily  parts  with. its  extra 
atom  of  oxygen,  and  only  differs  in  its  bleaching  effect  from  hydrogen 
dioxid  by  the  action  of  its  by-product.  • •  ', 


156 

When  sodium  gives  up  its  atom  of  oxygen  it  becomes  sodium  hydroxid 
NagO,  which  has  decided  saponifying  action  upon  all  vegetable  and  animal 
oils  and  fats,  and  a  solvent  action  on  animal  tissue. 

I  have  called  attention  to  its  value  as  a  pulp  canal  cleanser  after 
devitalization. 

The  tendency  of  this  agent  then,  is  not  only  to  chemically  change  the 
coloring  matter  in  the  dentin  of  discolored  teeth,  but  also  to  saponify  and 
dissolve  the  contents  of  the  tubuli. 

Theoretically  at  least  this  is  the  ideal  bleaching  agent,  because  it 
removes  more  thoroughly  than  either  agent  the  contents  of  the  tubuli  and 
consequently  the  normal  tooth  translucency  is  restored  instead  of  the 
opaque  whiteness  which  often  follows  other  methods.  For  bleaching  pur- 
poses it  is  used  in  two  different  ways,  and  each  has  its  advocates. 

It  is  mostly  used  in  the  form  of  a  saturate  solution  in  distilled  water. 
This  solution  must  be  carefully  made,  as  the  tendency  is  on  combining 
with  water  to  lose  its  extra  oxygen  by  the  heat  generated  in  the 
combination. 

The  solution  is  easily  made  by  placing  a  small  graduate  glass  con- 
taining half  an  ounce  of  distilled  water  in  a  large  pan  of  broken  ice ;  into 
this  a  tiny  bit  of  fine  powder  is  taken  on  a  wooden  spatula  and  gently 
sliaken  into  the  glass ;  this  should  be  repeated  every  fifteen  minutes  until 
the  solution  assumes  a  milky  appearance  throughout,  indicating  that  a 
saturate  solution  has  been  obtained.  In  a  few  minutes  the  cloudiness  will 
disappear,  when  the  solution  is  ready  for  use.  The  method  of  using  this 
solution  is  exactly  the  same  as  already  described  for  hydrogen  dioxid 
except  that  instead  of  cotton,  asbestos  wool  should  be  used  as  a  means  of 
applying.  The  solution  should  be  allowed  to  remain  for  about  five 
minutes,  when  the  dentin  should  again  be  washed  and  thoroughly  dried, 
then  another  application  and  so  on  for  three  or  four  times,  and  while  the 
dentin  is  thus  saturated. 

A  10  per  cent  solution  of  sulphuric  acid  is  applied  to  neutralize  the 
alkali  and  liberate  hydrogen  dioxid,  which  aids  in  still  further  bleaching 
When  the  desired  point  has  been  reached  the  dentin  should  be  thoroughly 
washed  with  warm  distilled  water  the  same  as  when  the  former  method 
has  been  used. 

Another  method  of  using  sodium  dioxid  has  recently  been  suggested. 
It  consists  of  placing  the  sodium  dioxid  powder  into  the  chamber,  and  to 
this  adding  distilled  water,  then  wash,  dry  and  repeat,  finally  flooding  the 
chamber  with  10  per  cent  sulphuric  acid  and  washing  the  dentin  as  above 
described. 


157 

Cblorin  method. 

The  chlorin  method  has  been  used  longer  than  any  other. 

It  consists  in  hberating  chlorin  gas  in  the  pulp  chamber  which  in  turn 
unites  with  the  hydrogen  of  the  coloring  substance  and  thus  destroying  its 
color.  The  agent  is  obtained  by  decomposing  calcium  hypochlorite  (chlor- 
inated lime),  in  the  pulp  chamber  by  the  action  of  dilute  acetic  acid. 
Another  method  of  using  chlorin  is  to  pack  the  chamber  with  chlorin  of 
aluminum  and  decomposing  the  same  with  hydrogen  dioxid,  in  which  case 
both  chlorin  and  oxygen  are  given  off — and  it  is  probable  that  the  oxygen 
is  the  bleacher.  In  the  chlorin  method  no  metallic  instruments  of  any 
kind  should  be  used,  even  gold  is  readily  acted  upon  by  chlorin  and  a 
yellow  insoluble  stain  results. 

When  the  bleaching  powder  is  placed  in  the  chamber,  and  the  other 
agent  applied,  the  opening  should  be  instantly  closed  with  gutta-percha 
in  order  to  prevent  the  ready  escape  of  the  chlorin,  and  in  very  bad  cases 
the  seal  may  be  left  24  hours  and  then  repeated  if  necessary.  Many  other 
agents  and  methods  have  been  tried.  At  one  time  some  operators  were 
very  enthusiastic  over  the  cataphoric  method,  but  none  of  these  at  all 
approached  the  direct  oxygen  method,  and  especially  do  I  regard  the 
sodium  dioxid  as  the  nearly  ideal. 

When  the  discoloration  is  due  to  metallic  stains  it  is  best  to  use  direct 
chlorin  method  and  follow  with  an  ammoniacal  solution  of  hydrogen 
dioxid.  In  a  general  way,  it  should  be  said  that  where  one  method  fails, 
others  should  be  tried,  and  even  by  so  doing  a  few  teeth  will  present  where 
little  can  be  accomplished  in  the  way  of  bleaching. 

The  best  lining  for  pulp  chamber  is  paraffin  where  that  can  be  used; 
it  gives  the  natural  translucent  effect,  which  nothing  else  does.  I  make 
a  solution  in  petroleum  ether,  and  coat  the  wall  toward  the  labial,  when 
conditions  will  permit,  and  then  fill  the  canal  and  chamber  with  white  oxy- 
chloride  of  zinc,  which  has  the  tendency  to  continue  the  bleaching  process. 
Before  concluding  this  chapter  let  us  repeat  a  few  important  points. 

Gutta-percha  must  be  the  root  filling  for  bleaching  cases.  The  gum 
must  be  carefully  protected  else  wide  destruction  will  be  the  result ;  cover 
exposed  tubuli  if  you  expect  permanent  results.  It  is  possible  to  carry  the 
bleaching  process  so  far  as  to  destroy  the  integrity  of  tooth  substance. 


CHAPTER  XV. 

Diseases  #f  the  Periaental  membrane  f)w\m  tbeir  Beginniitg 

at  the  6ittdivus. 

Calcic  Inflammation.     Salivary  Calculus.     Treatment.     Removal  of  ^Salivary  Cal- 
culus.    Scalers.      Removal    of   Stains   from    the   Teeth.      Serumal    Calculus. 
Phagedenic  Pericementitis.      Etiology   of  Phagedenic   Pericementitis. 
Treatment  of  Serumal   Calcic   Inflammation  and  Phagedenic 
Pericementitis      Diagnosis.     Treatment.     Instruments. 
Prognosis.     Management  of  Loose  Teeth. 


In  Chapter  XII,  we  studied  those  diseases  of  the  peridental  mem- 
brane affecting  its  apical  portion,  and  also  reviewed  its  histology,  to 
which  the  reader  is  asked  to  refer  before  beginning  a  study  of  this  chapter, 
for  the  reason  that  the  subject  matter  presented  liere  can  best  be  under- 
stood with  the  histology  fresh  in  mind.  The  reader  is  asked  especially  to 
note  the  arrangement  of  the  fibers  at  the  gingivus. 

The  peridental  membrane  is  subject  to  a  great  variety  of  diseases, 
many  of  which  are  little  understood.  Some  of  these  diseases  have  their 
origin  in  the  membrane,  and  others  in  the  immediate  surrounding  parts. 
These  diseases  seem  to  become  more  and  more  prevalent  with  advancing 
civilization ;  and  yet  we  have  convincing  evidence  that  the  prehistoric 
races  suffered  from  some  of  these  diseases  to  a  degree. 

The  prevalence  of  these  diseases  is  partly  accounted  for  by  the  fact 
that  human  teeth  were  designed  to  chew  coarse  foods,  and  as  our  habits 
have  changed  in  this  regard,  so  the  teeth,  gums  and  jaws  have  deterior- 
ated. Organs  that  are  not  used  atrophy.  Then  again,  the  excursion  of 
coarse,  tough  foods  over  the  teeth  and  gums  tends  to  clear  them  of  ac- 
cumulating mucous  and  debris,  and  thus  help  in  the  preservation  of  the 
health  of  these  organs.  Perhaps  the  outdoor  life  of  our  ancestors,  with 
its  consequent  robust  health,  had  something  to  do  with  the  health  of  the 
organs  of  mastication.  Be  that  as  it  may,  the  facts  are  that  more  teeth 
are  lost  from  these  diseases  than  all  other  causes  combined. 

For  many  years  these  diseases,  in  a  general  way,  were  known  to  exist, 
and  spoken  of  as  one  disease.  Dr.  J.  M.  Riggs,  of  Hartford,  Conn.,  was 
one  of  the  first  to  call  the  attention  of  the  profession  to  this  trouble,  and 
outlined  a  kind  of  treatment  in  1875,  hence  the  term  Riggs  disease  was 
given  to  it ;  other  names  that  were  applied  to  it  were  spongy  gums,  scurvy 
of  the  gums,  diseased  gums,  inflammation  of  the  gums,  gingivitis,  and 
latterly,  pyorrhea  alveolaris. 


159 

This  latter  term  has  been  quite  generally  accepted  by  the  profession 
as  the  most  expressive  of  the  conditions ;  it  signifies  a  copious  discharge 
of  pus  from  the  alveolus,  which  is  very  often  present  in  these  cases,  but  not 
always.  If  the  term  could  be  restricted  to  those  cases  which  it  describes 
I  can  see  no  objection  to  it. 

About  the  year  1887  Dr.  G.  V.  Black  presented  a  classification  of 
these  diseases  that  seemed  to  more  nearly  describe  conditions  found,  and 
yet  there  are  cases  that  do  not  come  within  this  classification.  Dr.  Black 
divides  these  diseases  into  three  classes :  Simple  Gingivitis,  Calcic  Inflam- 
mation and  Phagedenic  Pericementitis. 

Simple  Gingivitis :  By  the  term  simple  gingivitis  is  meant  those  in- 
flammations of  the  gum  which  are  not  the  result  of  calculus  irritation. 
The  simplest  form  of  gingivitis  we  meet  with  is  seen  in  young  people,  and 
occasionally  where  the  teeth  are  clean.  The  gums  become  red  and  swol- 
len, and  bleed  upon  the  slightest  touch ;  the  margin  may  be  slightly  thick- 
ened and  everted,  although  the  inflammation  is  not  usually  of  a  destruc- 
tive nature.  It  is  usually  transcient,  caused  by  some. slight  constitutional 
disturbance,  and  readily  subsides  when  the  teeth  are  kept  clean. 

A  solution  of  resorcin  used  around  the  free  margin  of  the  gum,  a  fresh 
fruit  diet  recommended,  supplemented  by  a  slightly  astringent  and  anti- 
septic mouth-wash,  is  usually  all  that  is  needed. 

In  others  this  inflammation  may  extend  so  as  to  include  the  entire 
gum  septum  and  alveolar  border.  In  these  cases  the  gum  is  usually  of  a 
purple  hue,  and  swollen  sometimes  so  as  to  completely  cover  one  or  more 
crown  surfaces  of  a  tooth,  or  several  teeth.  Gums  in  this  condition  are 
more  or  less  painful,  and  always  bleed  on  the  slightest  touch.    Fig.  45. 


Fig.  45. 

Showing    hypertrophy    of    gum    gingivus.       (Burchard.) 

Treatment  consists  of  cleaning  the  toothneck  and  scraping  the  alve- 
olar border  where  exposed,  free  blood  letting  and  using  powerful  astrin- 
gent applications  such  as  iodide  of  zinc  crystals,  sulphate  of  copper,  alum, 
glycerite  of  tannin. 

Treatment  should  be  daily  at  first,  and  then  every  third  day  supple- 
mented with  massage  and  vigorous  brushing,  and  the  use  of  astringent 
mouth-wash  several  times  daily.     There  is  another  form  of  simple  gingiv- 


i6o 

itis  which  seems  to  affect  the  gum  tissue  at  the  hngual  or  labial  surface  of 
upper  incisors,  labial  surface  cuspids  and  lingual  of  first  molars. 

The  gum  at  first  swells,  and  then  drops  away,  leaving  the  root  ex- 
posed for  a  considerable  distance  above  the  enamel  line.  There  is  no  pus 
or  tendency  to  bleeding,  and  all  that  can  be  done  is  to  cleanse  the  surface 
by  frequent  massage^,  and  instruction  should  be  given  the  patient  in  the 
proper  use  of  the  brush,  so  as  to  keep  the  parts  clean,  and  not  force 
the  gum  farther  away. 

The  most  severe  forms  of  gingivitis  occurring  where  there  are  no  de- 
posits are  constitutional  in  origin,  and  are  usually,  but  not  always,  the 
result  of  the  presence  in  the  system  of  such  drugs  as  phosphorus,  mer- 
cury, lead  and  iodine,  which  are  excreted  by  the  fluids  of  the  mouth,  par- 
ticularly the  mucous  and  peridental  membrane  fluids.  This  will  be  con- 
sidered in  the  next  chapter. 

There  is  another  variety  which  I  regard  as  the  result  of  poor  elimi- 
nations, auto-intoxication,  in  which  all  the  secretions  of  the  mouth  arc 
foul,  and  the  gums  hypertrophied  and  very  tender ;  teeth  are  sore  and  the 
tongue  badly  coated.  This  can  only  be  cured  by  proper  physical  treat- 
ment under  the  physician's  direction,  and  all  that  is  needed  of  the  dentist 
is  to  cleanse  the  teeth  and  mucous  surfaces,  provide  the  patient  with  a 
suitable  mouth-wash  and  otherwise  meet  the  local  conditions  by  such  treat- 
ment as  each  case  may  require. 

It  is  impossible  to  enumerate  all  the  kinds  of  cases  that  come  under 
this  class,  but  I  think  sufficient  has  been  said  to  point  to  the  kind  of  treat- 
ment needed  for  all.  I  am  quite  sure  that  simple  gingivitis  often  leads 
to  more  serious  diseases  of  the  peridental  membrane  itself.  When  the 
gingivae  becomes  swollen,  from  any  cause,  and  there  is  an  accumulation 
of  foul  mucous  and  debris,  it  affords  a  good  lodgment  for  bacteria.  The 
gums  soon  become  sore,  teeth  tender  and  consequently  are  not  kept  clean, 
because  of  the  pain  and  the  bleeding  upon  brushing.  In  most  inflamma- 
tions of  this  kind  the  patients  will  not  use  the  teeth  for  masticating,  and 
therefore  the  gums  do  not  have  the  benefit  of  that  natural  method  of 
cleaning,  and  this  is  another  reason  why  they  become  more  tender  and 
inflamed.  Such  conditions  also  favor  deposit  of  calculus.  When  calculus 
is  present  this  rapidly  passes  into  calcic  inflammation. 

0iikic  Tnflamntation. 

By  the  term  calcic  inflammation  I  mean  inflammation  of  the  gums 
and  the  peridental  membrane,  caused  and  maintained  by  the  presence  of 
calcuhis  on  the  necks  of  the  teeth.  This  is  one  of  the  most  serious  of  all 
diseases  of  the  peridental  membrane.  The  degree  of  inflammation  is 
dependent  upon  the  amount  and  nature  of  the  deposits.     The  greater 


i6i 

number  of  these  cases  I  see  leads  me  to  conclude  that  some  of  these  de- 
posits are  much  more  irritant  than  others.  Cases  occasionally  present 
with  large  quantities  of  calculus  on  the  crowns  and  around  the  necks, 
Avith  little  or  no  accompanying  inflammation ;  and  then  again  others  will 
show  the  most  violent  inflammation  resulting  from,  a  very  small  amount 
of  calculus. 

The  calculus  is  of  two  varieties,  named  with  reference  to  the  source 
from  which  they  come.  These  two  forms  occur  separately  or  together; 
one  above  the  other  or  mixed  throughout. 

Salivary  Calculus. 

The  form  most  commonly  found  is  known  as  salivary  calculus,  and 
is  deposited  by  the  saliva.  These  deposits  are  composed  of  earthy  matter, 
consisting  of  saliva  mucous,  animal  matter  and  phosphate  of  calcium,  and 
perhaps  other  salts.  It  is  usually  most  thickly  deposited  on  those  teeth 
situated  nearest  the  openings  of  the  ducts  of  the  salivary  glands,  namely, 
the  upper  first  molar  and  lower  incisors  and  cuspids.  It  is  deposited  just 
above  the  gum  or  occasionally  extending  slightly  under  the  gum  margin. 
The  amount  of  this  sort  of  deposit  on  the  teeth  seems  to  depend  largely 
upon  two  things :  First,  personal  uncleanliness  and  carelessness  about 
thoroughly  brushing  the  teeth ;  second,  upon  certain  constitutional  dis- 
turbances. This  form  of  calculus  is  most  readily  deposited  at  night,  when 
the  tongue  and  saliva  are  quiet,  and  hence  the  need  of  a  most  thorough 
brushing  of  the  teeth  upon  arising.  If  taken  thus  early  most  of  it  can 
be  brushed  off  before  it  has  thoroughly  hardened.  Especially  is  this  true 
if  a  stiff,  properly  shaped  brush  is  used  in  connection  with  some  good 
tooth  powder.  From  this  standpoint,  the  most  important  time  to  brush 
the  teeth  is  upon  arising  in  the  morning. 

As  to  the  constitutional  cause,  I  can  say  but  little.  We  have  not  yet 
found  out  all  there  is  to  be  known  in  this  direction,  but  certain  it  is  that 
there  are  some  systemic  conditions  that  favor  these  deposits.  One  in- 
dividual who  may  be  quite  careless  about  brushing  his  teeth  may  have 
little  or  no  deposits,  and  someone  else  who  may  be  very  particular  in 
this  regard,  may  be  troubled  very  annoyingly.  All  that  we  know  to  do 
that  will  aid  the  system  is  to  prescribe  large  quantities  of  fresh  fruit 
juices,  to  be  taken  especially  before  retiring,  also  the  drinking  of  large 
quantities  of  water. 

In  these  cases  of  salivary  calcic  inflammation  as  fast  as  the  peridental 
membrane  is  destroyed,  the  gum  recedes,  and  the  space  is  soon  covered 
with  fresh  deposits ;  this  process  goes  on  gradually  until  after  a  time  the 
alveolar  border  is  absorbed,  and  the  tooth  appears  to  have  grown  up  out 
of  the  socket  until  it  becomes  very  unsightly.     Oftentimes  the  gum  sep- 


l62 

turn  is  destroyed,  and  the  entire  alveolus  disappears,  and  the  tooth  drops 
out.  Whenever  these  deposits  occur  they  destroy  the  tissue,  and  then 
deposit  fresh  calculus  on  the  ground  gained.  The  membrane  is  not  de- 
stroyed to  any  great  extent  in  advance  of  the  deposits. 

Occasionally,  I  see  cases  where  the  salivary  calculus  seems  to  deposit 
over  the  edge  of  the  gums  in  great,  thick  masses,  covering  nearly  the 
whole  tooth  crown.  Particularly  does  this  often  occur  with  lower  in- 
cisors.    See  Fig.  46. 


Fig.  46. 
Deposits  of  salivary   calcu- 
lus.     (Barrett.) 

treatment 

The  treatment  necessary  for  the  relief  of  calcic  inflammation,  when 
due  to  the  salivary  variety,  is  very  simple.  It  is  always  well  to  scrub  the 
teeth  and  gums  with  hydrogen  dioxide  on  a  large  ball  of  cotton  carried 
in  the  pliers,  the  first  thing;  next,  syringe  around  the  teeth  with  1-2-3 
water,  to  remove  as  much  infectious  material  as  possible,  and  render 
everything  as  nearly  antiseptic  as  possible.  These  precautiojjs  will  often 
prevent  severe  inflammation  following  the  cleansing  of  the  teeth. 

The  essential  thing  in  the  management  of  all  calcic  inflammations  is 
the  thorough  removal  of  the  deposits,  which  is  a  simple  matter  when  only 
the  salivary  variety  is  present. 

Remcval  of  Salivary  Calculus. 

There  are  two  general  plans  of  procedure  followed  in  the  removal  of 
salivary  deposits,  one  known  as  the  push  method,  and  the  other  known  as 
the  pull  method.  In  the  push  method  the  general  shape  of  the  scaler  is 
that  of  a  chisel,  the  edge  of  which  is  brought  to  bear  on  the  deposit  at  a 
point  nearest  the  occlusal  surface,  forcing  the  deposit  away  with  a 
chiseling  motion.  In  the  pull  method  the  scaler  is  hooked  at  the  lowest 
point  of  the  deposit,  just  under  the  free  margin  of  the  gum,  forcing  the 
deposit  off  by  pulling  toward  the  occlusal.  Each  of  these  methods  has 
its  advocates,  and  the  method  easiest  for  one  operator  may  not  be  for 
another,  and  perhaps  the  great  majority  of  operators  use  both  methods,  as 
seems  most  convenient  for  the  different  locations. 


i63 

In  the  use  of  either  method  it  is  essential  that  the  scaler  be  grasped 
firmly,  and  the  guide  finger  be  firmly  braced  on  the  occlusal  surface,  or 
the  occluso-labial  or  buccal  angle,  of  the  neighboring  teeth  particularly, 
is  the  essential  when  the  push  motion  is  used,  in  order  to  prevent  acci- 
dents and  serious  injury  to  the  gums  or  peridental  membrane.  Where 
the  deposit  requires  considerable  force  for  its  dislodgment,  patients  are 
fearful  lest  the  instrument  slip  and  injure  them  seriously,  especially  when 
the  push  motion  is  used.  The  operator  should  always  take  pains  to  allay 
such  apprehension ;  first,  by  verbal  assurances,  and  second,  by  firmly  brac- 
ing the  guide  finger. 

The  operator  should  always  arrange  the  patient  in  such  positions 
in  the  chair  as  will  enable  him  to  get  at  the  various  locations  in  the  mouth 
in  the  most  accessible  manner.  The  mirror  should  be  used  to  reflect  light, 
and  at  the  same  time  hold  back  the  cheek,  lips  and  tongue,  as  may  be  re- 
quired from  time  to  time.  The  operator  should  stand  firmly  on  both  feet, 
and  have  nothing  around  that  will  interfere  with  his  free  movement 
about  the  chair,  and  he  should  learn  to  assume  as  comfortable  a  position 
as  possible,  for  there  is  nothing  so  fatiguing  and  eventually  so  ill-health- 
producing  as  standing  for  hours  in  strained,  unnatural  positions,  which,  if 
we  allow  ourselves  to  assume,  soon  become  a  habit,  from  which  it  is  dif- 
ficult to  break  away. 

In  scaling  the  lower  teeth,  the  operating  chair  should  be  at  the  low 
position,  patient  in  upright  position,  and  the  operator  free  to  move  about 
from  side  to  side,  sometimes  assuming  a  position  in  front  or  right  of 
patient,  then  to  right  back  of  patient,  and  left  front,  according  as  each 
position  will  bring  in  direct  view  the  tooth  surface  upon  which  he  is 
working. 

Scalers. 

The  scalers  which  I  find  admirably  adapted  for  the  purpose  intended 
are  illustrated  in  Fig.  47.  For  several  reasons,  it  seems  best  to  begin  the 
removal  of  salivary  calculus  on  the  lingual  surfaces  of  the  lower  incisors 
first.  At  that  point  the  deposit  is  thickest,  and  consequently  a  good  im- 
pression is  made  at  the  outset  on  the  mind  of  the  patient  as  to  the  desir- 
ability and  necessity  of  having  the  scaling  done,  and  also  because  most 
easily  removed  at  this  point  the  patient  gets  over  the  fear  or  dread  of  the 
operation,  before  the  more  difficult  places  are  undertaken. 

Scaler  Number  10  is  intended  to  remove  the  heavy  mass  of  the  deposit 
in  this  position,  and  Number  9,  in  addition,  to  go  in  between  the  teeth 
better,  and  Numbers  5  and  6,  being  right  and  left  push,  are  used  to  com- 
plement the  other  two,  and  especially  to  finish  up  after  the  larger  part  has 
been  removed  with  9  and  10;  7  and  8  are  used  to  scrape  around  under  the 


1 64 


■:: 
G 

Fig.  47. 
MaWhinney  scalers. 

gum  margin,  to  remove  any  particles  left  by  the  other  instruments.  In  the 
use  of  these  instruments  the  rest  finger  is  braced  on  the  adjacent  teeth, 
and  with  firm,  positive  strokes  the  deposit  is  dislodged,  always  holding  the 
mirror  in  the  left  hand,  with  which  the  tongue  is  held  back  and  light  re- 
flected on  the  field  of  operation.  In  removing  deposits  on  the  lingual  sur- 
faces of  all  the  lower  teeth,  the  author  finds  the  right  front  position  most 
convenient,  occasionally  changing  to  left  front,  if  teeth  incline  out  of  nor- 
mal position. 

After  the  lingual  surface  and  mesio-lingual  and  disto-lingual  angles, 
are  thus  cleaned,  using  i  and  2,  I  proceed  to  the  labial  and  buccal  surfaces 
and  angles  in  exactly  the  same  manner,  passing  from  the  incisors  to  the 
third  molar  on  the  right,  then  left,  cleaning  one  tooth  at  a  time  as  I  go. 
As  I  get  to  the  posterior  part  of  the  mouth  I  use  3  and  4  instead  of  i  and 
2,  although  Number  2  is  well  adapted  to  remove  the  calculus  from  the 
mesial  surface  of  bicuspids  and  molars.  I  should  also  repeat  here  that 
warm  antiseptic  solutions  in  the  syringe  with  which  to  wash  away  all 
loosened  calculus  must  be  at  hand,  and  frequently  used.  I  like  this  plan 
better  than  that  of  allowing  the  patient  to  take  the  solution  from  a  glass, 
which  consumes  much  time  unnecessarily,  although  a  glass  of  antiseptic 
solution  should  be  at  hand  for  the  patient  to  use  in  case  conditions  arise 
requiring  it. 

The  operator  should  always  be  careful  that  chips  of  tartar  do  not  fly 
into  his  eyes.  I  have  known  two  very  serious  accidents  which  occurred  in 
that  way. 

In  scaling  the  upper  teeth  the  chair  should  be  raised,  and  the  patient's 
head  thrown  well  back,  and  the  front  position  taken,  turning  the  head  so 
as  to  bring  each  surface  of  each  tooth  into  direct  view.     I  begin  at  the 


i65 

upper  right  third  molar  distal  surface,  passing-  around  to  the  buccal,  using 
Number  4;  then  from  distal  to  lingual,  using  Number  3,  and  on  the  mesial, 
using  Number  2.  I  proceed  in  exactly  the  same  manner  with  the  second 
and  first  molar,  but  with  the  bicuspids  and  incisors  I  use  Number  i  for 
the  distal.  When  I  get  to  the  median  line  I  take  the  left  third  molar, 
using  Number  3  for  the  distal  and  buccal  surfaces,  and  Number  4  for 
the  lingual,  and  pass  along,  completely  cleaning  one  tooth  at  a  time,  until 
the  median  line  is  again  reached,  using  7  and  8  for  finishing  up,  the  same 
as  directed  for  the  lower  teeth. 

After  all  the  teeth  have  been  thoroughly  scaled  they  should  be  pol- 
ished, to  remove  all  stains. 

Removal  of  Stains  from  the  tcetb. 

For  the  purpose  of  polishing  the  crown  surfaces  of  the  teeth,  many 
iiseful  appliances  have  been  devised,  the  best  of  which  are  in  the  form 
of  rubber  cups,  wheels,  cones,  moose-hide  points,  brushes  and  wood 
points,  all  of  which  are  to  be  used  in  the  engine,  and  carry  pulverized 
pumice,  moistened  with  hydrogen  dioxid. 

Care  must  be  observed  not  to  lacerate  the  gum  or  burn  the  tissues, 
which  is  a  thing  likely  to  occur  unless  appliances  of  proper  shape  are 
selected.  The  rubber  cup  is  usually  most  convenient  for  polishing  around 
the  gum  margin,  and  the  brush  for  other  surfaces.  As  a  final  touch,  the 
approximal  surfaces  should  be  polished  with  the  flattened  point  of  a  rose- 
wood stick,  carrying  the  pumice. 

When  the  polishing  is  complete,  silk  floss  should  be  passed  between 
all  the  teeth  to  remove  any  tartar  or  pumice  that  may  have  lodged  there, 
and  the  whole  gum  margins  flushed  with  warm  antiseptic  solutions  in  the 
syringe,  to  wash  out  every  particle  of  pumice,  and  finally  the  patient 
should  rinse  the  mouth  thoroughly  with  a  palatable  antiseptic  solution. 
The  patient  is  now  ready  to  receive  such  instruction  as  to  the  proper  care 
of  his  teeth  as  his  case  may  require,  and  further  appointments  made,  if 
other  attention  is  necessary, 

Serumal  0alculu$. 

Many  different  names  have  been  given  to  these  deposits,  most  com- 
mon of  which  are  sanguinary  deposits,  gouty  deposits,  black  tartar  and 
serumal  calculus.  The  last  term  seems  to  be  most  generally  accepted. 

Serumal  calculus  has  its  source  in  the  blood  stream,  and  probably  di- 
rectly from  the  serum  of  the  blood  that  exudes  through  the  tissues  about 
the  teeth.  It  seems  quite  certain  that  diseased  conditions  about  the  gum 
margins  favor  the  deposition  of  serumal  calculus.  Probably  all  of  the 
various  forms  of  gingivitis  already  alluded  to  act  as  exciting  causes. 
These  deposits  often  occur  on  teeth  in  mouths  kept  scrupulously  clean. 


1 66 

From  a  clinical  standpoint,  there  does  not  appear  to  be  much  differ- 
ence in  different  specimens  of  this  variety  of  calcuius. 

Dr.  Pierce  held  to  the  idea  that  serumal  calculus  contained  large 
quantities  of  urates  and  uric  acid,  and  that  its  presence  in  calculus  was 
largely  a  result  of  the  presence  in  the  system  of  unusual  quantities  of 
urates  and  uric  acid,  and  that  gout}^,  rheumatic  and  albuminuric  individ- 
uals suffered  mostly.  This  idea  was  and  is  also  held  by  Magitot,  Tru- 
man, Darby,  Kirk,  Marshall,  Reese.  On  the  other  hand,  Talbot  states 
that  only  6  per  cent  of  a  thousand  specimens  of  different  cases  examined 
were  found  to  contain  uric  acid  or  urates  in  any  form,  and  claims  the 
serumal  calculus  is  deposited  as  a  result  of  disease  conditions  present  in 
the  alveolus  surrounding  the  tooth. 

The  great  objection  I  see  to  the  uric  acid  theory  is  that  many  indi- 
viduals suffer  from  this  kind  of  calcic  inflammation  when  there  cannot 
be  found  any  trace  of  gout  or  rheumatic  tendencies,  and  no  excess  of 
urates  can  be  found  in  the  system;  and  again,  many  who  suffer  from 
gout  and  rheumatism  in  most  severe  acute  and  chronic  forms  do  not  have 
the  least  signs  of  calcic  inflammation.  Then,  again,  many  severe  cases  get 
well  permanently,  when  only  local  treatment  is  given. 

Perhaps  no  investigator  along  this  line  has  done  so  much  work  as 
Dr.  Talbot.  He  claims  that  both  serumal  calcic  inflammation  and  phage- 
denic pericementitis  are  slightly  different  manifestations  of  the  same 
disease,  and  that  its  immediate  seat  is  in  the  alveolar  process,  and  not  a 
disease  of  the  peridental  membrane.  He  has  given  the  name  interstitial 
gingivitis  to  this  trouble. 

Dr.  Talbot's  theory  regarding  the  diseases  which  the  profession  in- 
cludes in  the  term  pyorrhea  alveolaris  is  about  as  follows :  "This  disorder 
is  a  local  inflammatory  condition  of  the  gums  tending  to  accelerate  their 
normal  tendency  to  disappearance  at  certain  period  of  stress,  or  involu- 
tion, of  which  the  changes  produced  by  old  age  are  a  type.  There  are 
two  great  causes — exciting  and  predisposing.  The  exciting  may  be  purely 
local,  or  a  local  expression  of  a  constitutional  state.  The  local  causes 
assigned  are  acute  inflammation  of  mucous  membranes,  catarrhal  states, 
germs,  fungi,  irregular  teeth,  lactic  acid,  pocket  disease,  serumal  calculi, 
uncleanliness  and  local  degeneracy. 

"The  constitutional  causes — heredity,  constitutional  disorders,  exces- 
sive lime  salt  secretion,  meat  eating,  nervous  exhaustion,  scorbutus,  uric 
acid  and  auto-intoxication  states." 

In  the  light  of  much  clinical  experience,  I  can  scarcely  agree  wath  all 
of  Dr.  Talbot's  conclusions,  particularly  regarding  those  cases  which  are 
here  classified  as  phagedenic  pericementitis — of  which  I  shall  hereafter 
speak ;  but,  in  the  main,  his  conclusions  seem  rational,  and  have  only  been 


1 67 

arrived  at  after  years  of  careful  research,  and  are  therefore  entitled  to 
honest  consideration.     His  book  on  this  subject  should  be  read. 

This  variety  of  calculus  is  usually  very  hard,  of  a  dark  brown  or 
black  color,  and  is  most  frequently  deposited  in  a  ring  just  underneath 
the  free  margin  of  the  gums.  There  are  no  specially  favorable  teeth 
where  this  variety  is  found.  It  occurs  on  any  and  all  teeth.  If  allowed  to 
remain  any  length  of  time  it  produces  severe  inflammation  of  gum  margin, 
and  often  destruction  of  the  gum  septum  and  alveolar  border.  See 
Fig.  48. 


Fig.   48. 
Showing  absorption  of  gum  gingivus  and   alveolus.     (Burchard.) 

Sometimes  these  deposits  occur  more  on  one  side  of  a  tooth  than 
another,  and  pass  rapidly  toward  the  apex,  covering  one  side  of  the  root 
completely,  in  which  case  the  gum  septum  will  have  disappeared,  and 
the  alveolus  as  well,  to  a  considerable  extent  on  that  side,  and  the  rest 
of  the  gum  and  peridental  membrane  remain  normal. 

There  are  other  cases  where  the  deposit  occurs  high  up  on  the  root, 
or  perhaps  between  the  roots  of  molars,  and  none  to  be  seen  around  the 
gingivus,  and,  indeed,  the  membrane  may  seem  to  be  attached  all  around 
the  gingivus,  and  yet  considerable  serumal  deposit  be  found  high  up  on 
the  root  (see  Figs.  49  and  50).     Often  there  will  appear  a  narrow,  tor- 


a 

Fig.  49. 
necrotic   tissue;   h,  serumal  calculus.     (Barrett.) 


1 68 


tuous  channel  leading  down  to  the  gingivus,  making  the  exact  location  of 
the  deposit  difficult  to  find ;  still  other  cases  are  seen  where  the  deposit  is 
high  up  on  the  root,  and  the  alveolar  wall  immediately  over  it  absorbed 
away,  and  perhaps  a  discharge  of  pus  coming  through  the  gum  immedi- 
ately over  the  deposit. 


Fig.  50. 
Serumal   calcic   inflammation.     A,    serum   calculus;   b,  inflammatory  corpuscles;   c,  d,  peridental 
membrane  intact;  e,  pulp.     (Burchard.) 

In  some  of  these  cases,  where  there  is  a  large  deposit  of  serumal  cal- 
culus on  one  side  of  the  tooth  only,  it  is  not  unusual  to  find  that  the  tooth 
is  drawing  away  from  its  position ;  particularly  is  this  true  if  the  deposit 
extends  high  up  toward  the  apex.  Frequently  this  condition  occurs  be- 
tween the  central  incisors.  Indeed,  I  have  seen  such  cases  where  the 
■centrals  have  separated  the  width  of  a  tooth.  It  is  simply  the  effort  of 
nature  to  get  away  from  the  irritant,  and  is  partly  due  to  the  fact  that 
the  peridental  membrane  which  holds  the  tooth  in  that  direction  is  de- 
stroyed, allowing  the  remaining  portion  of  the  membrane  to  draw  the 
tooth  away  toward  the  opposite  side.  In  this  case  the  gum  septum  may 
:still  be  intact,  although  in  most  instances  the  septum  of  the  alveolus  is 
fcompletely  destroyed,  and  pus  will  be  found  flowing  from  the  socket. 

The  gum  and  peridental  membrane  continue  to  recede,  and  in  some 
cases  salivary  calculus  is  deposited  above  the  original  ring  of  serumal 
calculus,  and  this  process  goes  on  until  the  tooth  becomes  very  loose  in 
its  socket.  Sometimes  these  mixed  deposits  will  encroach  upon  the  apex, 
but  more  usually  the  deposit  is  of  serumal  variety.     I  have  often  seen 


169 


large  deposits  pass  up  on  one  side  of  the  root  until  the  apex  was  reached, 
resulting  in  the  death  of  the  pulp.    Figs.  51,  52,  53. 

In  all  of  these  cases  the  remaining  peridental  membrane  becomes  very 
much  thickened  and  tougher,  and  in  attempting  to  extract  these  teeth, 
.after  treatment  has  failed,  you  will  be  surprised  at  the  force  required  to 
remove  them.    Oftentimes  the  membrane  is  so  firmly  attached  to  the  gum 


Fig.   51. 

Serumal      calculus      covering 
root   of   lower   bicuspid. 


the 


Fig.   52. 
Serumal   calculus   covering  root   of 
an  upper   cuspid,   gum  tissue   was  in 
normal    position. 


at  some  point  as  to  result  in  badly  tearing  the  tissues  unless  care  be 
taken  to  cut  it  loose.  I  have  frequently  had  cases  where  the  teeth  were 
so  very  loose  that  with  the  finger  you  could  turn  the  apex  out  of  the  socket, 
but  it  was  firmly  attached  on  one  surface  by  the  peridental  membrane, 
which  made  it  necessary  to  clip  off  the  gum  on  that  side;  otherwise  I 
should  have  torn  a  great  amount  of  gum  tissue  and  periosteum  in  the 
operation.  As  a  precautionary  measure,  it  is  well  to  pass  a  thin,  sharp 
lancet  around  the  neck  of  the  tooth,  and  cut  loose  all  attachment  before 
removing  these  very  loose  teeth. 

The  important  thing  for  the  operator  to  remember  regarding  the 
etiology  of  this  disease  is  that  the  immediate  cause  of  calcic  inflamma- 
tion is  the  deposits  present  on  the  tooth  root,  and  the  first  step  in  the 
treatment  thereof  is  to  thoroughly  remove  every  particle  of  calculus, 
which,  with  this  variety,  is  not  always  an  easy  task,  but  when  success- 
fully done,  recovery  in  ordinary  cases  is  very  rapid. 

Inasmuch  as  the  scaling  of  teeth  where  serumal  calculus  is  present 
does  not  dififer  from  that  necessary  in  phagedenic  pericementitis,  I  shall 


i^o 


Fig.  53. 

Serumal    calculus    covering   root   of  molar. 


reserve  the  description  of  that  technique  and  subsequent  treatment  until 
after  that  subject  is  presented. 

Phagedenic  Pericementitis. 


The  term  phagedenic  pericementitis  was  first  suggested  by  Dr.  G. 
V.  Black,  in  1883,  and  while  I  cannot  say  it  has  been  very  generally 
accepted  by  the  profession,  yet  it  seems  most  expressive  of  the  conditions 
present  in  this  disease. 

Phagedenic  pericementitis  is  a  destructive  inflammation  of  the  peri- 
dental membrane,  which  may  or  may  not  be  accompanied  by  calcific  de- 
posits, and  is  nearly  always  accompanied  with  pus. 

It  usually  has  its  beginning  in  some  form  of  gingivitis,  and  most  fre- 
quently starts  at  the  gingivus  and  passes  up  along  the  root,  destroying 
the  peridental  membrane  as  it  progresses.  Sometimes  it  passes  along  one 
side  of  the  root  in  a  narrow  channel,  which,  toward  the  apical  third,  will 
widen  out,  forming  a  very  distinct  pocket.  Other  times  it  may  affect 
all  of  one  side  of  a  root,  either  mesial,  distal,  labial  or  lingual,  and  I  do 
not  think  it  can  be  said  that  one  side  is  more  liable  to  be  aft'ected  than 
another.  The  channel  often  takes  a  very  tortuous  course,  and  oftentimes 
the  pocket  will  be  found  on  one  side  of  a  root  and  the  point  of  discharge 
or  starting  point  at  the  gingivus  on  another  side.  In  other  cases  there 
may  be  no  pockets,  but  a  progressive  destruction  of  the  entire  membrane 
all  around  the  tooth,  but  this  form  is  not  very  common. 

There  are  still  other  cases  where  the  pockets  seem  to  have  no  con- 
nection with  the  gingivus,  but  form  high  up  on  the  root,  with  a  discharge 


171 

of  sero-pus  through  an  opening  in  the  gum  directly  over  the  pocket. 
Careful  examination  must  be  made  in  this  class  of  cases,  in  order  to 
avoid  mistaking  it  for  a  chronic  alveolar  abscess  dependent  upon  the 
death  of  the  pulp.     See  Fig.  50. 

In  this  class  of  cases  the  point  of  discharge  differs  somewhat  from 
the  fistulous  opening  or  "gum  boil"  of  an  alveolar  abscess,  in  which  the 
discharge  is  through  a  small,  conical,  tit-like  projection,  with  the  bone 
underneath  in  fairly  hard  normal  condition,  while  in  this  variety  of 
phagedenic  trouble  the  point  of  discharge  is  wide  open,  with  gum  tissue 
around  it  slightly  elevated,  thickened,  very  red,  and  will  bleed  on  the 
slightest  touch,  and  the  bone  underneath  absorbed  to  considerable  extent, 
so  that  an  explorer  will  readily  pass  through  the  outer  opening  directly 
to  the  root,  revealing  a  root  denuded  of  pericementum  over  a  large  area, 
for  in  all  these  cases  the  pockets  tend  to  spread  laterally  along  the  mem- 
brane, never  forming  pockets  which  lead  away  from  the  tooth  to  any  ex- 
tent, but  are  largest  next  to  the  tooth. 

Many  of  these  cases  come  to  us  while  still  in  the  acute  form,  and  will 
present  considerable  soreness  and  show  these  raised  areas  on  the  gum 
over  the  root,  which  has  never  broken  and  discharged  pus,  and  yet  if  you 
take  a  fine,  sharp  explorer,  you  will  be  able  to  pass  it  through  this  area 
directly  to  the  root,  and  discover  that  much  of  the  root  has  lost  its  mem- 
brane. 

I  have  seen  many  cases  of  this  kind,  particularly  on  the  labial  sur- 
face of  cuspids  and  buccal  surfaces  of  upper  molars  and  bicuspids,  where, 
try  as  hard  as  I  could,  I  was  not  able  to  find  an  opening  at  the  gingivus 
leading  to  the  pocket,  and  yet  when  I  opened  the  pocket  with  a  lancet  I 
found  roots  bare  to  a  considerable  extent,  in  many  cases  extending  from 
the  gingival  third  to  the  apex,  bringing  about  the  death  of  the  pulp,  and 
oftentimes  find  such  roots  covered  with  serumal  deposits,  and  many  cases 
have  no  such  deposits.  Recently  I  had  a  case  of  a  lady  of  about  forty 
years  of  age,  where  two  upper  bicuspids  had  such  pockets,  involving  the 
entire  middle  third  of  the  roots,  with  small  openings  at  the  lingual 
gingival  margin  of  each.  The  gum  was  in  normal  position,  but  the  teeth 
were  very  loose,  and  digital  pressure  on  the  gum  brought  away  great 
quantities  of  pus.  The  general  health  of  the  patient  was  such  as  to  pre- 
clude any  attempt  at  treatment,  so  the  teeth  were  removed,  bringing  away 
the  gingival  third  of  the  buccal  alveolar  plate,  and  revealing  the  fact  that 
the  middle  third,  and  extending  almost  to  the  apex,  had  lost  its  mem- 
brane, and  yet  there  were  no  deposits  of  any  kind.  This  was  a  true 
phagedenic  case  in  acute  form,  which  had,  as  nearly  as  could  be  ascer- 
tained, been  developed  within  three  months'  time.  In  my  private  prac- 
tice, as  well  as  in  the  infirmary  of  the  school,  I  have  seen  many  such  cases, 


1/2 

but  the  percentage  is  small  compared  to  those  which  are  complicated  with 
serumal  deposits. 

In  many  cases  where  tbe  disease  has  progressed  slowly,  you  may  see 
a  decidedly  thickening  of  the  bone,  particularly  at  the  gingivus,  which  is 
brought  about  by  the  mild  stimulation  of  the  osteoblast,  resulting  from 
continuous  irritation.  Usually  the  membrane  has  lost  its  attachment  to 
the  cementum,  and  the  bone  next  to  the  tooth  absorbed  some- 
what, and  the  thickening  occurs  by  building  on  the  outer  surface 
of  the  bone. 

Where  these  pockets  exist,  we  occasionally  see  large  absorption  of 
tooth  substance.  I  have  collected  several  specimens.  The  absorbed  areas 
present  a  variety  of  shapes,  from  broad,  rough,  shallow  places,  to  small, 
round  holes,  that  look  almost  as  though  they  had  been  made  with  a  drill. 
I  am  very  glad  to  say,  however,  that  these  cases  are  rare. 

With  regard  to  the  development  and  progress  of  phagedenic  perice- 
mentitis, it  should  be  said  that  cases  present  a  wide  difference. 

Some  cases  begin  and  go  on  violently,  until  the  tooth  becomes  so 
loose  that  it  is  lost  within  a  few  weeks ;  others  progress  very  slowly,  and 
take  years  to  produce  any  serious  trouble.  In  some  cases  the  teeth  early 
become  very  sore,  sensitive  to  thermal  changes,  and  the  seat  of  neuralgic 
pains  that  become  very  severe.  In  other  cases  the  development  and  pro- 
gress of  the  trouble  is  painless,  and  the  first  indication  of  trouble  is  the 
looseness  of  the  tooth ;  more  particularly  is  this  true  of  simple  phagedenic 
cases,  that  is,  those  cases  not  complicated  with  serumal  deposits.  In  such 
cases  there  sometimes  is  no  apparent  inflammation  of  the  gums ;  on  the 
contrary,  they  often  appear  anemic. 

etiology  of  Phagedenic  Pericementitis. 

All  observers  seem  to  agree  as  to  the  clinical  aspect  of  these  cases, 
but  there  is  a  wide  difference  of  opinion  regarding  its  etiology. 

Dr.  G.  V.  Black  states  that  the  disease  is  fundamentally  one  of  the 
peridental  membrane  affecting  its  attachment  to  the  tooth ;  fiber  by  fiber 
that  membrane  is  torn  away  from  the  cementum,  and  is  the  result  of 
specific  infection,  probably  due  to  a  special  micro-organism  vv^hich  has 
not  been  isolated  as  yet,  although  he  has  done  much  work  in  an  endeavor 
to  find  it. 

Dr.  George  W.  Cook  is  of  the  same  opinion,  and  has  done  a  great 
amount  of  work,  resulting  in  finding  a  germ  that  he  thinks  is  responsible 
for  the  trouble.  Certain  it  is  that  he  has  produced  similar  pockets  by 
introducing  this  germ  under  the  gum,  particularly  where  some  irritation 
of  the  gingivus  already  existed. 


/6 


Dr.  M,  L.  Rhein  presents  some  interesting  theories.  He  calls  this 
disease  pyorrhea  alveolaris,  and  divides  it  into  two  general  classes,  which 
he  terms  pyorrhea  simplex  and  pyorrhea  complex. 

Under  the  head  pyorrhea  simplex  he  includes  all  those  cases  of  what 
he  calls  purely  local  origin,  and  which  are  amenable  to  simple  local 
treatment. 

Pyorrhea  complex  he  regards  to  be  of  constitutional  origin,  present- 
ing slightly  different  forms,  according  to  the  physical  disorder  of  the 
patient,  which  forms  are  readily  recognizable. 

This  class  he  subdivides  into  four  groups,  according  to  their 
causation. 

(a)  Those  due  to  disorders  of  nutrition,  gout,  diabetes,  nephritis, 
scurvy,  chlorosis,  chronic  rheumatism,  anemia,  leukemia,  pregnancy. 

(b)  Those  resulting  from  acute  attacks  of  infectious  diseases,  among 
which  he  specified  typhoid  fever,  tuberculosis,  malaria,  acute  rheumatism, 
pleurisy,  pericarditis,  syphilis. 

(c)  Those  due  to  nervous  disorders,  cerebral  disease,  spinal  disease, 
neurasthenia,  hysteria. 

(d)  Those  conditions  which  are  the  result  of  drug  poisoning,  par- 
ticularly mercury,  lead  and  iodides. 

It  is  doubtless  true  that  many  of  these  diseases  do  make  a  distinct 
impression  in  the  mouth,  but  as  a  cause  for  pyorrhea  alveolaris  they  can 
only  be  considered  as  predisposing  and  never  as  the  exciting  cause,  be- 
cause all  forms  of  this  disease  are  seen  in  the  mouths  of  individuals  who 
have  never  had  any  of  the  diseases  enumerated,  and,  again,  individuals 
who  have  suffered  from  many  of  these  diseases  have  never  had  the  slight- 
est indication  of  peridental  trouble ;  and,  again,  most  forms  of  this  trouble 
yield  to  local  treatment. 

Dr.  Talbot's  theories,  which  have  already  been  explained,  are  to  the 
effect  that  this  disease  has  its  seat  in  the  alveolar  process,  to  which  I  sug- 
gest the  following  criticism:  If  the  process  is  the  seat  of  trouble,  why 
does  the  membrane  lose  its  attachm.ent  to  the  tooth  first?  Many  cases 
that  I  have  examined  show  the  membrane  attached  to  the  bone  and  torn 
away  from  the  cementum.  Again,  why,  on  the  removal  of  the  aft'ected 
teeth,  does  the  disease  terminate  without  further  treatment?  Why  does 
the  disease  never  occur  in  edentulous  jaws? 

Dr.  J.  W.  Younger  believes  the  disease  to  be  purely  local,  and 
caused  by  a  special  germ.  He  states  that  from  years  of  experience  in 
managing  these  cases  he  very  rarely  finds  one  that  will  not  yield  com- 
pletely to  local  treatment. 

I  have  had  several  patients  who  continually  suffered  from  simple 
phagedenic  trouble  requiring  constant  watching.     No  sooner  would  one 


174 

pocket  be  healed  than  the  patient  would  return  with  one  or  more  new 
pockets  filled  with  pus,  perhaps  on  teeth  that  had  never  been  affected 
before.  And  after  years  of  this  constant  watching-,  the  trouble  would 
entirely  disappear  following  some  severe  illness,  and  in  four  cases  has  not 
reappeared  in  five  years,  and  one  case  in  ten  years.  Clearly,  then,  the 
changed  physical  condition  had  something  to  do  with  the  disappearance  of 
the  disease. 

I  think  I  have  collected  enough  opinions  to  show  the  reader  that 
the  mind  of  the  profession  is  not  made  up  regarding  the  etiology  of  this 
disease,  but  that  there  is  a  great  difference  of  opinion  regarding  this 
point.  I  have  faith  to  believe  that  soon  new  light  will  be  thrown  on  this 
subject,  for  many  able  men  are  bending  their  best  energy  to  the  solution 
of  this  problem. 

Crcatttieitt  of  Sertitntil  Calcic  TnfUtnmation  ana  PDddeaeHic  Pericementitis. 


Diasnosis. 

The  first  step  in  the  management  of  these  cases  is  a  correct  diagnosis. 
We  need  to  know  exactly  what  the  conditions  are. 

In  making  a  diagnosis,  first  get  a  complete  history  of  the  case ;  find 
out  about  the  character  of  the  pain;  how  long  has  the  trouble  existed? 
Have  any  teeth  been  lost  from  this  cause?  Are  the  teeth  sore  to  pres- 
sure ;  tender  to  hot  and  cold  drinks ;  sweet  and  sour  things  ?  Are  any 
teeth  loose?  Has  there  been  any  swelling?  Is  there  an  offensive  odor 
and  a  bad  taste  in  the  mouth  ?    Do  the  gums  bleed  readily  ? 

A  knowledge  of  these  things  gained  from  the  patient  not  only  is 
helpful  to  the  operator,  but  has  a  good  mental  influence  on  the  patient. 

The  instruments  needed  to  make  a  thorough  examination  are  two 
explorers,  a  mouth  mirror,  a  mouth  lamp,  supplemented  by  a  well- 
trained  index  finger.  After  learning  the  history  of  the  case,  a  good 
way  to  make  the  mouth  examination  is  to  begin  with  a  general  survey  of 
the  entire  mouth  ;  then  with  a  surgically  clean  index  finger  pass  it  along 
the  gum  high  up,  and  then  along  the  gingivus,  and  on  labial,  buccal  and 
lingual  surfaces  of  gum,  using  enough  pressure  to  detect  any  soft,  tender 
places,  and  to  force  any  pus  present  out  at  the  gingivus.  Next  press  on 
the  teeth  to  determine  looseness  and  tenderness,  and  observe  if  any  of  the 
teeth  have  moved  out  of  normal  position ;  and,  finally,  with  mouth  lamp 
and  mirror  to  light  up  every  pocket,  proceed  with  proper  explorers  to 
examine  every  surface  of  every  tooth,  passing  the  explorer  around  the 
free  margin  of  the  gum,  dropping  it  into  each  pocket,  noting  its  shape, 
and  the  character  of  the  deposits.     All  the  points  observed  should  be 


175 

written  down  for  future  reference,  and  particularly  should  this  be  done 
if  the  case  is  sent  to  you  for  consultation. 

treatment. 

The  first  essential  in  the  treatment  of  these  diseases  is  thorough 
cleaning  of  the  teeth.  Even  in  simple  phagedenic  cases,  thorough  scraping 
of  the  root  at  every  point  where  the  membrane  has  separated  from,  the 
cementum  is  necessary,  because  there  are  always  present  either  concretions 
of  calculus  or  pus  globules,  or  other  foreign  matter  which  must  be  re- 
moved. 

Instruments. 

The  instruments  necessary  to  do  this  work  must  be  small,  of  good 
texture,  and  so  shaped  as  to  readily  reach  every  surface  of  all  the  teeth 
roots  in  the  mouth.  Many  sets  of  scalers  have  been  devised  for  this 
purpose,  each  possessing  certain  merits.  The  Younger  set  of  thirty- 
seven  answers  admirably  for  those  who  are  skilled  in  their  use,  but  I  am 
satisfied  they  are  too  complicated  for  use  of  general  practitioners,  re- 
quiring years  of  constant  using  to  become  proficient.  The  Harlan  and 
Gushing  sets  are  used  by  many  operators.  The  Tompkins  set  has  ex- 
cellent points. 

The  author's  set  (Fig.  47)  was  devised  especially  for  students'  use, 
and  presents  the  following  points : 

1.  The  cutting  edge  is  in  line  with  the  shaft,  so  the  instrument  does 
not  roll  in  the  fingers  under  stress. 

2.  The  shapes  are  admirably  adapted  to  reach  every  surface. 

3.  They  are  small,  with  rounded  backs,  and  therefore  injure  the  gum 
less  than  other  sets. 

4.  They  are  stiff,  and  will  not  spring  over  hard  deposits  under  stress. 

5.  They  are  easily  sharpened. 

In  the  main,  the  points  that  have  been  insisted  upon  for  the  removal 
of  salivary  calculus  hold  good  in  the  removal  of  serumal  deposits,  to 
which  the  reader  is  referred  for  the  instrumental  technique.  The  im- 
portant thing  is  to  get  it  all  off,  which  I  can  assure  you  is  never  an  easy 
task.  Always  instruct  your  patient  as  to  the  conditions  and  necessary 
treatment. 

The  following  outline  of  procedure  should  prove  helpful : 

First. — Clean  the  gums  with  hydrogen  dioxid  on  a  swab  of  cotton, 
and  with  an  antiseptic  solution  in  the  syringe  flush  out  all  debris  from 
around  the  necks  of  the  teeth. 

Second. — Keep  the  working  end  of  the  scalers  immersed  in  an  anti- 
septic solution. 


176 

Third. — Select  some  point  in  the  mouth  to  begin  on,  and  proceed 
from  that,  thoroughly  cleansing  one  tooth  at  a  time. 

In  this  class  of  cases  I  begin  with  the  lower  right  third  molar,  and 
pass  around  the  lower  jaw  first,  and  then  take  the  upper  in  the  same  way. 
The  important  thing  is  to  take  one  tooth  at  a  time  and  confine  all  your 
thought  and  energy  to  that  one,  until  the  scaling  of  it  is  completed. 

Fourth. — When  the  pockets  are  deep  and  the  tissues  tender,  1  always 
pack  the  pockets  with  a  rope  of  cotton  saturated  with  one  per  cent  solu- 
tion of  cocain  in  peppermint  water,  previously  packing  bibulous  paper, 
gauze  or  absorbent  cotton  around  the  tooth,  to  prevent  any  of  the  cocain 
solution  escaping  into  the  throat.  The  cotton  rope  should  be  left  in  the 
pocket  for  two  or  three  minutes. 

Fifth. — If  the  tooth  neck  is  very  sensitive,  I  dry  it  and  lay  30  per 
cent  chloride  of  zinc  around  it  for  a  few  minutes. 

Sixth. — If  the  pockets  are  tortuous  and  the  gingivus  tight  around 
the  tooth,  I  pack  the  gum  away  with  a  rope  of  zephyr  wool,  saturated  in 
25  per  cent  phenosulphonic  acid,  for  twenty-four  hours,  which  will  not 
only  gain  ready  access,  but  will  tend  to  soften  the  deposits. 

Seventh. — If  the  pocket  is  high  up,  the  gum  tight  around  the  tooth 
neck,  and  the  outer  plate  of  the  alveolus  over  the  middle  or  apical  third 
destroyed,  I  invariably  make  an  opening  through  the  gum  at  that  point, 
through  which  to  do  the  scaling. 

Eighth. — Where  the  pocket  is  very  large  and  membrane  entirely  de- 
stroyed at  that  point,  it  is  well  to  curette  the  bone  as  well  as  the  tooth,  and 
treat  as  a  surgical  wound. 

Ninth. — Use  the  explorer  frequently  to  determine  the  progress  made 
in  scaling  on  each  surface.  Special  care  is  needed  in  the  grooves  and 
depressions  in  root  surfaces. 

Tenth. — Flush  the  pockets  frequently  with  antiseptic  solutions,  to 
keep  a  clean  field  upon  which  to  work. 

Eleventh. — Where  the  teeth  are  very  loose  some  method  of  fixation 
must  be  adopted,  for  loose  teeth  never  can  recover  unless  held  immovably. 

Twelfth. — In  very  bad  cases  the  pulp  should  be  destroyed  and  canals 
filled.     If  pulp  is  dead,  root  canals  must  receive  first  attention. 

The  operator  should  be  cautioned  against  attempting  too  much  at  one 
sitting,  for  not  only  does  the  patient  become  fatigued,  but  the  operator 
loses  that  delicacy  of  touch  which  is  so  essential  to  successful  work. 

Sometimes  a  whole  sitting  will  be  consum.ed  in  scaling  a  single  tooth, 
but  one  tooth  well  done  is  far  better  than  more  half  done. 

In  very  bad  cases  radical  measures  are  necessary  to  bring  about 
changed  conditions.  Dr.  A.  W.  Harlan  has  said,  in  efifect,  that  in  some 
of  these  cases  you  need  to  tear  up  and  literally  burn  the  tissues  involved 


177 

before  recovery  will   result.      Growth   through   stimulation  by   irritation 
seems  to  be  the  thought. 

Most  operators  find  the  pull  motion  produces  less  pain,  and  is  more 
positive  in  its  results  than  the  push  motion.  In  the  pull  method  the  scaler, 
of  proper  shape,  is  carried  to  the  bottom  of  the  pocket  first,  and  gradually 
worked  toward  the  crown,  removing  and  reinserting  the  scaler  as  few 
times  as  possible.  I  always  use  Numbers  7  and  8,  which  can  be  used  with 
either  a  push  or  pull  motion  to  finish  up  with.  They  are  admirably 
adapted  for  reaching  into  grooves,  crevices  and  all  irregular  surfaces. 

In  very  bad  cases,  where  the  membrane  is  largely  destroyed,  many 
operators  recommend  extraction,  cleansing,  filling  root  canals,  deepening 
the  socket,  and  replanting.  Oftentimes  one  root  of  a  molar  may  be 
removed  and  the  remaining  one  or  two,  as  the  case  may  be,  carry  the 
tooth  successfully.     These  operations  will  be  described  in  another  chapter. 

After  the  instrumentation  has  been  completed,  the  pockets  should  be 
thoroughly  washed  to  remove  all  debris  and  blood  clot,  which,  if  not 
removed,  make  a  favorable  field  for  the  growth  of  micro-organisms. 

I  do  not  recommend  hydrogen  dioxid  for  this  purpose,  except  in 
those  cases  where  the  pockets  are  wide  open,  for  there  is  danger  of  the 
rapid  efi^ervescence  tearing  away  the  attached  membrane. 

As  a  first  treatment,  many  operators  use  concentrated  lactic  acid  for 
its  irritant  stimulating  effect;  others  use  30  per  cent  chloride  of  zinc,  10 
per  cent  trichloracetic  acid,  sulphate  of  copper  powder,  campho-phenique, 
Black's  I,  2,  3,  resorcin,  hydronaphthol,  iodide  of  zinc,  tincture  of  iodine, 
some  of  the  silver  salts,  and  a  lot  of  other  remedies  have  been  suggested.  In 
my  hands  a  combination  of  iodine  and  iodide  of  zinc  have  proven  very 
efficient  for  the  ordinary  case.  This  remedy  was  suggested  by  Dr.  Talbot, 
and  is  made  of  five  parts  of  iodine  crystals;  seven  parts  of  iodide  of  zinc; 
glycerine  to  make  thin  cream.  Sometimes,  if  the  pockets  are  large  and 
flow  of  pus  profuse,  I  will  burn  it  out  with  50  per  cent  phenosulphonic 
acid,  and  pack  it  with  chinosol  gauze,  wdiich  I  leave  for  forty-eight  hours. 
In  the  average  case  I  dry  the  gum  and  pocket  as  well  as  I  can,  and  flow  on 
the  gum.,  and  into  the  pockets  Talbot's  glycerol  iodine  and  zinc  freely, 
keeping  them  dry  with  a  piece  of  aseptic  dental  napkin  for  a  couple  of 
minutes,  when  the  excess  may  be  washed  ofif  with  antiseptic  solution  in 
the  syringe,  and  the  mouth  rinsed.  The  patient  must  return  in  twenty- 
four  hours,  when,  if  there  is  pus  present,  I  feel  certain  that  at  that  point 
the  tooth  has  not  been  thoroughly  cleansed,  and  I  proceed  to  do  so. 

It  is  very  rare,  indeed,  that  pus  presents  at  the  third  sitting. 

If  the  case  is  progressing,  I  do  not  again  open  the  pockets,  but  allow 
the  same  medicine  to  flow  down  by  gravity,  or  capillary  attraction.  Of 
course,  at  each  sitting  the  gum  and  necks  of  the  teeth  must  be  cleansed,  for 


•        178 

which  purpose  I  usually  use  a  warm  antiseptic  solution  in  a  compressed  air 
atomizer. 

I  repeat  this  treatment  every  third  day  for  a  week  or  so ;  then  every 
fourth  day;  then  once  a  week,  and  so  on,  never  dismissing-  a  case  under 
three  months,  except  in  rare  instances. 

I  frequently  change  to  plain  tincture  of  iodine,  especially  if  the  gums 
get  very  sore  from  the  iodine  and  zinc,  and  if  the  necks  of  the  teeth  are 
very  sensitive  I  use  chloride  of  zinc,  nitrate  of  silver,  or  trichloracetic  acid, 
as  conditions  indicate.  The  patient  should  always  be  provided  with  an 
antiseptic  astringent  mouth  wash,  and  good  tooth  powder. 


^ 

Sodii  bcras^ 

3  iv 

Acidi  Carbol^ 

3  i 

Glycerite  Tannin, 

3ii 

Tinct.  Myrrh, 

3i 

Ol.  Cassia, 

3  ss, 

Ol.  Pepperminti, 

m.x. 

Alcoholis, 

o  ii 

Aquae  dist.,  q.  s.  ad. 

§  vi 

M.  Sig.     Use  a  teaspoonful  in  one-quarter  glass  of  warm  water 
as  a  mouth  wash  several  times  daily. 

This  should  be  supplemented  by  thorough  brushing,  using  a  good 
powder  and  a  hard  brush.  Daily  massaging  the  gums  with  the  fingei 
moistened  with  the  above  solution,  directing  the  force  toward  the  tooth 
crown,  will  also  prove  helpful  in  most  cases.  The  patient's  general  health 
must  be  looked  after ;  all  the  functions  of  the  body  must  be  normally  per- 
formed. The  eliminative  organs  should  be  stimulated.  The  daily  drinking 
of  eight  glasses  of  pure  water  should  be  insisted  upon,  and  a  minimum 
amount  of  sweets  and  meats  taken,  and  the  patient  should  be  encouraged 
to  eat  plenty  of  fresh,  ripe  fruit,  and  to  take  wholesome  exercise  in  the 
open  air. 

In  a  work  of  this  kind  it  is  impossible  to  do  m.ore  than  indicate  the 
line  of  treatment  that  should  be  followed,  but  the  operator's  knowledge 
of  the  conditions  and  the  remedies  at  hand  will  be  able  to  modify  the 
treatment  for  each  individual  case. 

A  few  things  must  be  kept  in  mind.  Perfect  cleanliness,  thorough- 
ness as  to  detail.  Insist  on  the  patient  doing  his  part,  and  do  not  tear 
open  the  pockets  or  poke  instruments  into  them  when  healing  has  once 
favorably  begun,  and  if  there  is  any  physical  cause  of  irritation,  such  as 
improper  contact  points,  rough  filling  margins,  improper  use  o-f  the  brush 
or  toothpicks,  these  must  first  be  attended  to. 


179 

Prognosis. 

Regarding  the  prognosis  of  these  cases  I  can  only  say  that  the  cause 
which  produced  it  in  the  first  place  will  bring  it  back,  and  that  no  positive 
assurance  can  be  given  the  patient  as  to  freedom  from  future  attacks,  and 
the  fact  that  such  attacks  recur  is  no  proof  that  the  disease  was  not  cured 
in  the  previous  attem.pt,  for  this  disease  is  not  like  smallpox,  in  which  one 
attack  insures  the  patient  against  a  future  one. 

Teeth  in  all  varieties  of  this  disease  have  been  cured  and  remained  so 
for  many,  many  years.  The  fallacious  notion  given  the  public  by  many 
dentists  that  this  disease  is  incurable  is  not  only  untrue,  but  it  is  unjust 
to  the  many  scientific  and  skilled  men  who  are  making  a  success  of  the 
treatment  of  the  great  majority  of  cases  presented,  and  equally  unjust  to 
those  who  suffer  and  lose  their  teeth  because  of  this  false  idea. 

Before  dismissing  this  subject,  a  word  should  be  said  regarding  the 
reattachment  of  the  peridental  membrane. 

Does  the  peridental  membrane  reattach  itself  when  once  torn  from 
the  cementum?  The  answer  must  be  in  the  affirmative,  when  the  con- 
ditions are  favorable.  If  the  membrane  is  attached  to  the  bone  side,  and 
only  separated  from  the  tooth  in  comparatively  small  areas,  and  the  tooth 
in  those  areas  has  been  thoroughly  cleaned,  the  membrane  will  lie  down 
on  the  cementum  and  reattach  its  fibres  by  a  new  deposit  of  cementum,  but 
if  tlie  membrane  is  totally  destroyed  over  any  considerable  area,  reattach- 
ment is  impossible,  and  only  a  mechanical  union  will  exist  between  the 
bone  and  cementum  at  those  points.  For  further  consideration,  see  chapter 
on  implantations,  etc. 

management  of  Eoose  teeth. 

Many  of  these  cases  present  with  one  or  more  teeth  loose,  and  before 
permanent  results  can  be  expected  the  teeth  must  be  held  firmly  in  the 
socket.  Oftentimes  teeth  are  so  loose  as  to  make  scaling  impossible  until 
they  are  held  firmly  in  the  socket.  ]\Iany  methods  and  appliances  have 
been  suggested  for  this  purpose,  most  of  v/hich  have  for  their  object  the 
binding  of  several  teeth  together  in  a  solid  compact.  Splints  of  either 
rubber  or  gold  are  frequently  made  to  fit  along  the  lingual  surfaces  of 
teeth  down  to  the  free  margin  of  the  gum,  and  ligated  in  position  by 
passing  either  gold  wire  or  silk  twist  through  small  holes  in  the  splint  to 
the  mesial  and  distal  of  each  tooth,  and  tying  on  the  labial  or  buccal. 

Another  method  is  to  swage  shallow  caps  to  fit  over  the  occlusal  where 
the  occlusion  will  permit.  This  mav  often  be  made  in  one  piece  to  cover 
several  teeth,  and  extending  over  the  labial  and  lingual  surfaces  about 
two  millimeters,  and  is  cemented  into  place.      (See  Fig.  54). 

Another  method  is  to  surround  each  tooth  with  narrow  bands  of 
o-auge  26,  22  karat  gold,  allowing  but  one  thickness  of  gold  between  the 


i8o 


Fig.   54. 

Swedged  gold  caps  to  retain  lower   incisors. 

teeth.  The  bands  should  be  on  the  occlusal  third  of  the  tooth,  and  held 
in  position  with  cement.  (See  Fig.  55.)  Many  operators  bind  the  teeth 
together  with  pure  gold  wire.      (See  Fig.  56). 


Fig.    55. 
Gold  bands  for  retaining  loose   lower   incisors. 


Showing 


Fig.  56. 
wire    ligature    for    retaining 


loose    teeth.       (Rhein.) 


When  it  is  only  necessary  to  hold  the  teeth  temporarily,  I  find  nO' 
better  way  when  teeth  on  either  side  of  the  loose  ones  are  present  than  to 
ligate  one  to  the  other,  using  silk  thread.  Take  a  case  where  two  lower 
centrals  are  loose.  I  begin  by  wrapping  number  A,  waxed  silk  thread 
twice  around  the  right  lateral,  tying  on  the  mesial  just  below  the  contact 
point ;  pass  it  around  the  right  central  in  exactly  the  same  way,  and  tie  on 
the  mesial,  and  so  on,  around  the  left  central  and  lateral.  A  little 
experience  will  enable  the  operator  to  adapt  this  same  plan  to  various 
locations  about  the  mouth. 

Take  this  same  case,  where  the  teeth  are  very  loose  and  the  alveolus 
largely  gone,  a  permanent  appliance  is  necessary,  and  for  this  purpose 
I  find  nothing  so  good  as  to  devitalize  the  pulps  in  the  four  incisors ; 
grind  the  lingual  surface  slightly  immediately  over  the  opening  made  for 


pulp  removal  and  canal  filling,  over  which  burnish  pure  gold,  each  tooth 
separately,  and  pass  a  short  post  into  each  canal ;  take  an  impression  with 
all  in  position,  make  a  cast  and  flow  solder  over  the  whole,  uniting  all 
together,  polish,  and  set  wath  cement.  I  have  several  of  these  splints  that 
have  been  worn  from  five  to  twelve  years,  with  the  utmost  satisfaction. 

The  same  method  can  be  adapted  to  the  upper  incisors  and  cuspids, 
and  oftentimes  without  devitalizing  the  pulps  by  making  the  hole  to  receive 
the  pin  to  the  mesio-lingual  or  disto-lingual  of  the  pulp.      (See  Fig,  57.) 


a  c 

Fig.  57. 
Splint    for   retaining   loose   teeth.       (Ames.) 


The  same  principle  can  be  adapted  to  molar  and  bicuspids,  using  the  oc- 
clusal instead  of  the  lingual  surface.  Oftentimes  by  cutting  a  groove 
extending  along  the  center  of  the  occlusal  from  one  tooth  to  the  other, 
into  which  a  heavy  platino-iridium  wire  is  laid,  around  which  amalgam 
or  gold  foil  is  packed,  a  permanent  result  is  obtained. 

The  Carmichael  attachment  is  admirably  adapted  for  this  purpose. 

AVhen  these  badly  diseased  teeth  are  situated  on  either  side  of  short 
edentulous  spaces,  good  results  are  often  obtained  by  cutting  off  and 
crowning  the  teeth,  and  bridging  in  the  missing  teeth.  I  have  several  such 
cases  that  have  remained  comfortable  for  ten  years.  It  goes  without  say- 
ing that  in  all  these  cases  the  usual  measure  to  effect  a  cure  must  be 
adopted,  and  carried  out. 

Before  dismissing  this  subject,  I  wish  to  speak  of  a  method  suggested 
by  Dr.  W.  V.-B.  Ames,  for  the  cure  of  the  disease,  and  the  retention  of 
loose  teeth,  particularly  lower  incisors  and  cuspids  that  are  very  loose,  and 
that  have  lost  much  of  the  alveolus  surrounding  them.  It  consists  in  de- 
stroying the  pulps,  filling  pulp  canals,  and  thoroughly  cleaning  the  teeth, 
after  which  he  saws  the  crowns  off  at  the  gum  line  and  bands  each  root 
the  same  as  for  a  Richmond  crown,  and  in  case  the  natural  crowns  are 
good,  he  utilizes  them  instead  of  porcelain  for  the  crown,  a  detailed  de- 
scription of  which  does  not  come  within  the  scope  of  this  book,  but  which 


1 82 

can  be  found  in  the  Dental  Cosmos,  May,  1903.  Dr.  Ames  claims  that 
by  this  method  he  not  only  fixes  the  teeth  firmly  in  position,  but  the 
gold  collar  acts  as  a  stimulant  aiding-  recovery. 


CHAPTER  XVI. 

gVPcrcemento$i$  and  Root  Resorptions. 

Morbid  Anatomy.      Causes    of   Hypercementosis.      Pathology.      Symptoms. 


The  terms  Hypercementosis  and  Excementosis  have  been  used 
synonymously  to  designate  a  secondary  deposit  of  cemenlum  on  the  tooth 
root ;  this  deposit  may  occur  upon  any  part  or  surface  of  the  root,  but  is 
most  frequent  about  the  apical  end. 

In  the  normal  process  of  tooth  formation,  cementum  is  deposited 
layer  upon  layer,  which  not  only  continues  until  the  root  has  assumed 
complete  form  but  slowly  continues  throughout  life.  Unless  disturbed  in 
the  process  of  formation  these  layers  pass  in  one  continuous  line  from  the 
enamel  line  to  apex,  differing  very  little  as  to  thickness  at  dififerent  points 
until  apex  is  reached,  where  it  becomes  slightly  thicker  and  at  the  enamel 
junction  it  tapers  off  quite  thin. 

morbid  Jfnatomy. 

It  is  difficult  to  say  exactly  where  hypertrophy  begins  and  the  normal 
physiological  formation  ends.  In  ground  specimens  it  is  clearly  seen  that 
a  certain  layer  often  becomes  greatly  hypertrophied  at  a  certain  point  and 
all  the  rest  of  it  formed  in  normal  thickness  (See  Fig.  58). 


Fig.  58. 
Hypercementosis.      A,  dentine;    b,    layers  of   cementum;    c,   peridental   membrane;    d,   thickened 
layer;   e,  same  layer  normal.      (Black.) 

Hypercementosis  may  occur  in  one  or  more  of  these  regular  layers 
or  lamellae,  and  it  may  occur  in  the  first  layer  or  any  or  all  subsequent 
layers,  and  in  many  ground  specimens  it  is  clearl}'  seen  that  absorption  of 
small  areas  of  previously  deposited  cementum  occurs,  which  is  afterwards 
filled  in  as  the  next  lavers  are  formed. 


i84 


Fig.  60. 
Hypercementosis    of   entire  root.      (Barrett.) 


Fig.    61. 
Hypercementosis,         round, 
smootli     form,    involving    ap- 
ical  third   of    root. 


Fig.   63. 
Hypercementosis,    with    de- 
posit   of    cementum    uniting 
root  apices. 


Fig.  63. 
Hypercementosis,    showing   the    union    of 
roots  of  two  molars. 


Fig.  64. 
Hypercementosis.      Union    of    distal    root 
of  lower   second  molar  with  mesial  root  of 
lower  third   molar. 


i85 

Teeth  affected  with  hypercementosis  present  a  variety  of  forms.  In 
some  cases  the  entire  root  is  enlarged  (see  Fig.  60)  ;  in  others  the  enlarge- 
ment is  confined  to  the  apical  third,  (Fig.  61,)  and  in  still  other  cases  the 
cementum  may  have  united  two  roots  of  the  same  or  adjoining  teeth. 
(Figs.  62,  63,  64.) 

The  accompanying  illustrations  will  furnish  interesting  study.     They 
are  made  from  specimens  among  the  writer's  collection.      (Fio-s    6^    66 
6y,  68.)  '       ' 


Fig.  65. 
Hypercementosis,    irregular 
form. 


Fig.  66. 
Hypercementosis,        round, 
smooth    form,    involving    the 
apical    third. 


Fig.  67. 
Hypercementosis,     irregular   form. 


Fig.   68. 
Calcific    structureless    mass 
involving     roots      of     molar. 
(Barrett.) 


0au$($  of  1)ypercemento$i$. 

As  to  the  causes  of  hypercementosis  very  little  can  be  definitely  stated. 
It  is  doubtless  due  to  some  undue  irritation,  which  disturbs  the  normal 
physiological  process.  It  seems  probable  that  many  times  the  irritant 
is  chemical  in  its  nature,  and  has  its  source  in  the  blood  of  the  surround- 
ing parts^  and  in  a  great  majority  of  cases  is  due  to  a  mild  form  of  irri- 
tation to  the  peridental  membranes. 

This  irritation  may  be  the  result  of  continued  extra  stress  on  the 
tooth,  difficulty  in  erupting  and  passing  into  normal  position,  and  certain 
forms  of  chronic  pericementitis. 

In  short  anything  that  will  cause  hyperemic  condition  of  the  peri- 
dental membrane,  and  through  that  and  over  activity  of  the  cementoblasts 
is  liable  to  cause  hypercementosis,  but  the  facts  are  that  a  very  small  per- 
centage of  teeth  subjected  to  unusual  stress  or  irritation  of  every  kind  are 
ever  affected  with  this  disorder. 

Pathology. 

The  pathology  of  hypercementosis  is  vague  and  uncertain,  and  many 
writers  are  of  the  opinion  that  it  has  no  defined  or  distinct  pathology. 

The  facts  are  that  most  of  the  cases  that  have  come  under  my  obser- 
vation presented  no  untoward  symptoms  of  any  kind,  and  were  only  dis- 
covered when  teeth  were  removed  for  other  reasons. 

A  few  writers  report  cases  where  hypercementosis  seemed  to  be  the 
cause  of  trigiminal  neuralgias ;  shifting  pains  about  the  face,  eyes  and 
ears  have  been  attributed  to  this  cause,  but  evidence  is  wanting  to  prove 
such  claims,  and  even  when  the  extraction  of  such  a  tooth  is  followed  by 
cessation  of  pain  does  not  prove  it  to  be  the  cause.  See  chapter  on  neu- 
ralgia. 

Diagnosis. — A  diagnosis  can  only  be  made  by  exclusion. 

When  every  other  possible  cause  of  these  disturbances  has  been 
examined  into  wnth  negative  results,  hypercementosis  may  be  suspected, 
but  the  only  means  of  positively  determining  the  existence  or  non-existence 
of  hypercementosis  is  the  X-ray. 

Resorption  of  the  roots  of  permanent  teeth. — By  this  term  is  meant 
the  absorption  of  portion  of  roots  of  permanent  teeth. 

As  has  been  previously  stated,  cementum,  and  even  dentin,  is  often 
absorbed  in  certain  areas  and  refilled  with  new  cementum,  and  this  appears 
to  be  a  purely  physiological  process. 

The  w^ork  of  cutting  out  is  doubtless  done  by  osteoclasts,  a  multi-nu- 
cleated cell,  M^hich  is  situated  here  and  there  among  the  pericementum 
fibers.  The  work  of  building  up  is  due  to  the  cementoblasts  which  have 
been  referred  to  in  the  beginning  of  Chapter  XII. 


i87 

Many  writers  are  of  the  opinion  that  when  absorption  is  going  on  at 
one  point,  an  extra  amount  of  cementum  is  being  deposited  at  another 
point.  At  what  point  the  absorption  process  can  be  called  pathological  I 
do  not  know,  but  it  is  my  opinion  that  the  entire  process  is  physiological 
and  is  Nature's  method  of  getting  rid  of  foreign  inharmonious  bodies. 

That  sometimes  this  normal  process  becomes  perverted  is  doubtless 
true,  but  as  to  why  such  is  the  case  we  do  not  know. 

Cause. — That  any  mild  irritant  is  likely  to  act  as  a  cause,  anything 
that  would  act  as  a  special  stimulus  to  the  osteoclasts  would  doubtless 
cause  resorption. 

In  these  hollowed  out  places  osteoclasts  are  found  in  great  numbers 
but  as  to  the  how  or  why  they  are  there  we  do  not  seem  to  know. 

The  process  is  exactly  the  same  as  that  occurring  in  implanted  teeth, 
but  differs  markedly  from  absorption  of  roots  of  temporary  teeth. 

Resorption  occurring  in  permanent  teeth  seems  to  attack  the 
cementum  much  more  rapidly  than  the  dentin.  In  all  the  specimens  that 
I  have  seen  even  when  the  apex  of  the  root  was  involved,  the  cementum 
was  removed  from  large  areas  of  dentin,  showing  that  dentin  is  more 
resistant  to  its  action,  while  if  you  examine  a  temporary  undergoing  this 
process  you  will  find  the  dentin  is  hollowed  out,  undermining  the 
cementum  to  considerable  extent. 

As  to  the  pathology  of  resorption  very  little  can  be  said  as  previously 
stated.  This  is  Nature's  method  of  getting  rid  of  any  aseptic  foreign  sub- 
stance, which  doubtless  explains  why  planted  teeth  lose  their  roots  by  this 
process,  because  it  must  be  quite  clear  to  every  one  that  a  planted  tooth, 
which  has  no  peridental  membrane  for  its  support  and  nourishment  can 
not  be  considered  as  anything  but  a  foreign  substance,  although,  of  course, 
more  in  harmony  with  its  surroundings  than  most  anything  else  that  could 
be  put  there. 

This  is  Nature's  method  of  getting  rid  of  teeth,  where  their  function  is 
accomplished,  but  once  in  a  while  a  temporary  tooth  fails  to  absorb,  and 
insists  on  remaining  even  when  the  permanent  one  is  ready  to  occupy  its 
place. 

Why  this  is  so,  we  do  not  know ;  a  good  deal  of  guesswork  has  been 
indulged  in  regarding  this  whole  subject,  and  very  little  fact  adduced. 

Symptoms. 

What  are  the  symptoms  of  root  resorption? 

I  do  not  know  of  any  except  in  cases  of  plantation  when  the  tooth 
often  has  short  periods  of  soreness,  an  itching  feeling  in  the  gums  and 
bone,  and  a  feeling  of  uncertainty  which  is  cleared  up  when  the  tooth 
loosens  and  droDS  out. 


Diagnosis. — In  this  case  also  a  positive  diagnosis  can  only  be  made  by 
the  X-ray. 

Treatment. — Relieve  the  conditions  that  present,  look  to  the  root 
canal,  and  the  peridental  membrane  and  relieve  any  irritation  that  can  be 
found  and  failing  to  relieve  and  make  the  tooth  comfortable,  extraction 
must  be  resorted  to. 


CHAPTER  XVII. 

Resection  of  Roots  ana  Plantation  of  Ceetb. 

Replantation    as   a   Cure   for   Alveolar    Abscess. 


The  operation  of  resection  consists  in  the  excision  and  removal  of  a 
portion  of  any  organ  ;  and  is  especially  applied  to  the  end  of  bones  and 
teeth.  The  resection  of  a  root  is  an  operation  for  the  removal  of  its  apical 
end,  although  the  term  is  often  applied  to  operation  for  the  renewal  of  an 
entire  root  of  a  two  or  three  rooted  tooth  to  which  the  term  amputation  is 
commonly  given. 

Elsewhere  I  have  alluded  to  the  fact  that  frequently  in  persistent 
alveolar  abscess  the  root  apex  is  partially  absorbed,  resulting  in  very  rough 
sharp  surfaces,  which  interfere  with  the  healing  process.  In  such  cases 
the  operation  of  resection  is  advised  especially  when  one  of  the  ten 
anterior  teeth  on  either  upper  or  lower  jaw  is  involved. 

On  the  molar  teeth  I  do  not  consider  this  operation  practical  except 
where  the  entire  root  is  to  be  removed.  The  first  step  in  resection  after 
the  root  canal  filling  is  completed  is  to  make  all  the  surrounding  tissues 
surgically  clean. 

Next  a  circular  incision  is  made  in  the  gum  over  the  root  apex  and 
the  flap  thus  formed  is  desected  up  and  held  with  a  suitable  instrument ; 
the  root  is  exposed  by  cutting  away  the  bone  with  a  suitable  bur  in  the 
engine,  oftentimes  the  bone  has  been  absorbed  to  considerable  extent 
making  this  part  of  the  operation  very  simple.  The  parts  should  now 
be  cleansed  and  bleeding  stopped.  With  a  bibevel  drill  a  hole  is  made  in 
the  center  of  the  root  a  little  above  the  point  at  which  it  is  desired  to  cut 
it  off,  Fig.  69 ;  into  this  hole  is  introduced  a  fissure  bur,  the  engine  run 
rapidly  cutting  to  right  and  left  from  the  hole,  thus  cutting  off  the  desired 
portion  which  can  easily  be  removed  with  a  small  excavator. 

The  root  end  should  be  carefully  rounded.     (Fig.  69B.) 

The  entire  pocket  should  be  thoroughly  curetted  and  washed  out  with 
antiseptic  gauze.  The  irrigation  and  packing  should  be  repeated  every 
two  or  three  days,  using  less  gauze  each  time  and  watching  that  healing 
from  the  bottom  occurs.  This  operation  is  not  difficult,  and  with  the  aid 
of  a  local  anesthetic  can  be  done  quite  painlessly,  and  the  results  are  quite 
satisfactory.  I  know  of  several  teeth  doing  good  service  that  were  thus 
treated  over  six  years  ago. 

Amputation. — The  removal  of  the  entire  root  of  a  molar  tooth  is  to 
be  recomm.ended  when  that  root  has  lost  its  membrane,  and  much  of  the 


190 


Fig.  69. 
A    diagram    of    tooth     with 
apex      absorption.         a,      the 
drill    hole;    B,    the    finished 
rounded    tooth    apex. 

alveolus  and  the  other  root  or  roots  are  sufficiently  healthy  to  insure  the 
useful  retention  of  the  tooth. 

In  some  severe  phagedenic  cases,  especially  when  complicated  with 
serumal  calculus,  we  often  find  the  lingual  root  of  upper  molars  so  badly 
diseased  that  recovery  is  impossible  and  yet  the  two  buccal  roots  may  be 
in  a  good  state  of  attachment ;  in  all  such  cases  amputation  of  the  lingual 
root  is  to  be  recommended. 

This  operation  is  very  simple  and  is  most  easily  done  with  a  fissure 
bur  in  the  engine,  cutting  off  the  root  on  a  level  with  the  bifurcation ;  the 
root  can  easily  be  removed  with  a  small  elevator  or  root  forcep.  A  stone 
should  then  be  used  with  which  the  tooth  at  this  point  should  be  beveled 
toward  the  occlusal  and  lingual  surface  so  that  no  shoulder  remains  on 
which  food  will  lodge  (see  Fig.  70). 


Fig.  70. 
Showing      upper      molar     with 
lingual    root    removed.     (Black.) 

The  socket  from  which  the  root  is  removed  should  be  curetted  and 
kept  clean  until  it  fills  in  with  bone,  which  will  be  an  added  protection 
to  the  remaining  roots. 

This  operation  is  adapted  to  lower  molars  as  well  and  in  rare  cases 
to  two  rooted  bicuspids  (see  Fig.  71).     The  prognosis  for  such  cases  is 


191 

-very  good,  a  great  majority  of  such  teeth  when  the  operation  has  been 
well  done  will  do  good  service  for  many  years.  Indeed,  I  regard  this 
operation  most  satisfactory  of  all  the  operations  suggested  in  this  chapter. 

Plantation. — The  plantation  of  teeth  has  been  practiced  for  many 
years  with  varying  success.  The  subject  matter  is  best  presented  under 
three  heads :  Replantation,  which  is  the  replacing  of  a  tooth  in  the  socket 
from  which  it  is  removed  ;  transplantation,  which  is  the  insertion  of  a 
natural  tooth  in  a  natural  socket  from  which  another  was  recently 
extracted  and  implantation,  which  is  the  insertion  of  a  tooth  root  in  a 
socket  in  the  alveolus  which  has  been  artificially  made. 

The  operation  of  replantation  has  been  practiced  for  many  years.  As 
far  back  as  I  have  access  to  the  literature,  I  find  dentists  have  recommended 
the  immediate  replacement  of  teeth  that  have  been  accidentally  lost. 
Indeed  mothers  and  fathers  have  frequently  replaced  teeth  of  their  chil- 
dren that  have  been  lost  by  accidental  means  such  as  blows,  kicks  of  horses, 
falls,  etc.,  especially,  when  a  thread  of  attachment  remained,  and  in  many 
cases  good  results  were  obtained.  These  facts  induced  dentists  to  remove 
teeth  that  were  hopelessly  diseased  either  from  alveolar  abscess  or  pyorrhea 
trouble  and  replant  them. 

Replantation  as  a  Cure  for  Jllweolar  Abscess. 

In  some  chronic  forms  of  alveolar  abscess  where  there  is  considerable 
absorption  of  bone,  replantation  has  been  suggested  as  a  cure  and  many 
successful  cases  are  reported,  but  this  practice  has  been  quite  generally 
abandoned  in  favor  of  the  more  successful  method  of  curetting  the  bone 
around  the  root  apex,  and  the  root  as  well  when  foreign  deposits  are 
present  or  resection  when  the  apex  is  absorbed  or  roughened. 

Replantation  as  a  cure  for  so-called  pyorrhea  alveolaris  was  practiced 
to  a  considerable  extent  a  few  years  ago,  but  at  the  present  time  has  fallen 
into  disrepute,  partly  because  of  improved  methods  of  treating  the  disease. 
The  operation  consisted  in  the  extraction  of  the  affected  tooth,  immersing 
it  immediately  in  antiseptic  solutions,  under  whch  it  is  thoroughly  cleansed 
of  all  foreign  matter  and  if  roughened  it  is  made  smooth. 

The, root  canal  is  cleansed  through  the  apical  end  unless  a  cavity  exists, 
then  the  canal  is  cjuickly  dried  and  filled  with  gutta-percha,  and  the  tooth 
again  immersed  in  the  antiseptic  solution,  where  it  should  remain  until  the 
socket  is  made  ready.  The  socket  is  thoroughly  curetted  and  slightly 
deepened,  and  the  tooth  inserted  while  fresh  hemorrhage  ensues. 

The  tooth  must  be  immobilized  by  the  use  of  bands,  caps  or  wire 
ligatures  as  seems  best  adapted  to  the  case.  This  practice  has  been  gen- 
erallv  abandoned  for  this  class  of  cases  because  at  best  the  alveolar  process 


192 

around  the  tooth  in  bad  pyorrhea  cases  has  already  been  destroyed  to  a  very 
considerable  extent,  and  it  is  therefore  quite  impossible  to  establish  a  socket 
that  will  retain  the  tooth  for  any  great  length  of  time ;  I  have  had  a  few 
cases  remain  two  years. 

Replantation  is  best  adapted  to  those  cases  where  healthy  teeth  have 
been  accidentally  dislodged  and  which  can  be  replaced  within  a  short  period 
of  time  after  the  accident. 

When  such  cases  can  be  attended  to  within  a  few  hours  of  the  accident, 
best  results  are  obtained.  In  every  case  the  root  canal  must  be  filled,  and 
the  whole  tooth  rendered  antiseptic,  and  the  socket  cleansed  of  blood  clot, 
and  if  possible  a  normal  hemorrhage  restored.  The  tooth  is  then  forced  to 
place  and  retained  by  some  of  the  appliances  previously  suggested. 

I  have  a  case  of  this  kind  where  two  centrals  have  remained  for  eight 
years,  and  are  still  doing  good  service. 

Transplantation. — When  from  any  cause  a  tooth  is  lost  from  a  com- 
paratively good  socket  it  may  be  replaced  by  another  tooth. 

There  are  several  things  in  the  way  of  this  operation  which  relate  to 
the  difficulty  of  getting  a  freshly  extracted  tooth  adapted  as  to  size,  shape 
and  denomination,  to  fit  the  already  existing  socket  and  m.any  a  patient  is 
reluctant  about  having  some  other  person's  tooth  in  his  mouth,  and  there 
in  some  danger  of  transmitting  disease. 

Some  operators  recommend  old,  dry  teeth,  but  I  have  not  been  suc- 
cessful in  their  use,  and  among  my  professional  acquaintances  I  find  the 
practice  has  been  quite  generally  abandoned,  although  there  might  be 
exceptional  circumstances  where  it  could  be  recommended,  but  a  freshly 
extracted  root  even  if  an  artificial  crown  is  necessary,  will  often  give 
sufficient  service  to  repay  for  the  trouble. 

Implantation. — Dr.  Younger  was  the  first  dentist  to  give  any 
prominence  to  this  operation  and  I  think  he  is  justly  entitled  to  the  author- 
ship of  this  operation  as  it  is  practised  at  the  present  time. 

His  first  great  recorded  operation  was  in  1885,  since  which  time  he 
has  probably  performed  it  more  than  any  other  operator,  and  his  success 
is  probably  due  to  his  splendid  skill. 

In  this  operation  a  tooth  is  taken  from  another  mouth  and  planted  in 
a  socket  which  is  artificially  made  in  the  alveolus.  The  operation  is 
intended  to  supply  a  missing  tooth  where  one  has  failed  to  erupt  or  where 
it  had  been  extracted  some  years  before.  Here  as  in  other  cases  a  freshly 
extracted  tooih  or  root  is  to  be  desired. 

The  special  instruments  necessary  with  which  to  perform  this  opera- 
tion are  the  Younger  trephines  illustrated  (Fig.  72)  ;  Ottofy  spiral  knives 
(Fig.  74),  and  the  Ottolengui  reamers  (Fig.  73),  and  a  few  long-shanked 
burs  of  dififerent  shapes  (Fig.  75). 


Fig.  71. 

Showing   lower  molar    with 
distal  root  removed.     (Black.) 


Fig.  73. 
Younger  trephines. 


Fig.  73. 
Ottolengui's  reamers. 


Fig.  74. 
Ottofy's  spiral  knives. 


,12        3       4 

Fig.  75. 
Long-shanked  burs  of  necessary  shapes. 


194 

The  first  step  in  this  operation  is  to  select  a  tooth  that  will  fill  the 
space  accurately,  and  if  a  root  an  artificial  crown  must  be  properly 
adjusted  both  as  to  shape,  form  and  contour. 

The  tooth  should  be  kept  in  an  antiseptic  solution,  and  all  the  work 
done  under  antiseptic  precautions. 

Local  anesthetics  are  all  that  are  usually  needed,  although  in  many 
cases  general  anesthesia  will  have  to  be  resorted  to. 

The  writer  follows  the  method  outlined  by  Dr.  Ottofy  in  1887,  which 
is  as  follows :  A  deep  incision  is  made  in  the  gum  and  periosteum  at  a 
point  that  will  form  the  lingual  gingivus  (Fig.  76),  and  turned  up  and 
out  toward  the  labial.     (See  Fig.  yj^. 


Fig.  76. 
Showing     Dr.     Ottofy's    in- 
cisions. 


Fig.  77. 
Showing    the    flap    as    sug- 
gested  by   Dr.   Ottofy. 


With  proper  trephines,  knives  and  burs  a  socket  is  drilled  to  receive 
the  new  root.  The  tooth  should  be  tried  in  the  socket  at  frequent 
intervals  to  insure  a  proper  fit,  bearing  in  mind  that  the  root  must  fit 
the  socket  very  tightly.  After  the  socket  is  drilled  it  must  be  cleared  of 
blood  clot  and  bone  chips  and  a  fresh  hemorrhage  started  into  which  the 
root  is  forced  and  retained  by  a  suitable  appliance.  Every  efl^ort  should 
be  made  to  keep  the  parts  antiseptic  until  healing  is  complete. 

General  considerations. — Planted  teeth  are  only  held  in  the  socket  by 
the  deposit  of  bone  around  the  root  and  the  union  is  only  a  mechanical  one. 

The  peridental  membrane  is  never  again  formed  or  reattached  except 
in  very  rare  instances  where  teeth  have  been  immediately  returned  to  other 
sockets  when  only  partially  knocked  out. 

Dr.  Younger  and  many  others  have  held  that  there  is  a  rejuvenation 
and  reattachment  of  the  membrane,  but  careful  investigation  does  not 
substantiate  their  claims. 

However,  it  must  be  said  that  such  teeth  often  become  more  firm 
in  the  jaw,  and  require  greater  force  to  dislodge  them  than  their  neigh- 
bors, which  is  accounted  for  by  the  fact  that  the  newly  formed  bone 
is  more  dense,  and  has  not  the  natural  channels  through  it  that  are  present 
in  the  normal  alveolus. 

When  planted  teeth  are  lost  it  is  usually  by  process  of  absorption. 
This  absorption  sometimes  begins  at  the  apex  and  gradually  proceeds 
crownward,  but  more  often  it  begins  on  the  sides  of  the  root ;  this  process 


195 

sometimes  ceases  for  a  time  and  bone  is  deposited  in  these  places,  but 
sooner  or  later  all  these  teeth  will  be  lost,  quite  after  the  plan  of  absorption 
of  temporary  teeth. 

The  operations  of  transplantation  and  implantation  should  be  con- 
fined to  the  incisors,  cuspids,  and  bicuspids,  and  should  only  be  attempted 
where  it  seems  very  undesirable  to  replace  the  missing  teeth  with  artificial 
ones  either  in  the  form  of  plates  removable  or  fixed  bridges. 

At  this  time  when  the  means  of  reproducing  the  natural  tooth  is  so 
good,  both  as  regards  appearance  and  usefulness  these  operations  are  not 
frequently  indicated  especially  when  we  remember  that  planted  teeth  only 
last  from  two  to  six  years,  and  at  best  not  more  than  fifteen  years. 

And  at  best  the  operation  is  quite  severe  on  the  patient  even  when 
an  anesthetic  is  employed. 


CHAPTER  XVIII. 


Diseases  of  tbe  Soft  tissues  of  tbe  IDouth. 

Stomatitis.    Aphthous  Stomatitis.     Treatment.     Ulcerative  Stomatitis.     Mercurial 

Stomatitis    (Ptyalism).      Symptoms.      Treatment.      Eczema    of   the 

Tongue.     Leukoplakia.     Causes.     Treatment. 


Stomatitis. 

The  word  stomatitis  is  of  Greek  origin  and  signifies  inflammation  of 
the  mouth. 

Acute  stomatitis  is  the  most  common  form  of  mouth  inflammation, 
and  is  usually  the  result  of  som.e  local  or  constitutional  irritant.  It  is 
frequent  in  all  ages  and  is  often  associated  with  acute  attacks  of  indiges- 
tion following  acute  specific  fevers. 

In  poorly  nourished  children  it  is  often  associated  with  dentition  or 
may  appear  as  a  result  of  some  gastro-intestinal  disturbance.  Tobacco 
users  often  suffer  from  this  affliction,  but  more  particularly  have  I  seen 
it  in  the  mouths  of  excessive  smokers  of  cigarettes. 

The  chief  characteristic  of  this  disease  is  a  general  redness  and  dry- 
ness of  the  gums,  sometimes  extending  to  all  the  membranes  of  the  mouth 
and  lips,  and  the  tongue  may  be  slightly  swollen,  furred  and  indented 
along  its  margins  by  the  teeth.  All  the  mucous  membrane  may  become 
tender  to  the  touch  and  severely  painful  in  mastication  and  particularly 
if  hot  drinks  be  taken.   - 

Sometimes  in  children  the  temperature  will  rise  one  or  two  degrees. 
Treatment  consists  in  removing  the  cause  as  far  as  possible  and  applying 
weak  solution  of  nitrate  of  silver  or  chloride  of  zinc,  three  grains  to  the 
ounce,  to  the  afflicted  parts,  and  the  frequent  use  of  a  borax  mouthwash. 

Jlpbthous  Stomatitis. 

This  form  is  often  spoken  of  as  follicular  or  vesicular  stomatitis. 
It  usually  appears  in  the  form  of  small,  slightly  elevated  spots  about  two 
ram.  in  diameter  surrounded  by  a  somewhat  reddened  zone ;  these  vesicles 
soon  rupture,  forming  ulcers  with  grayish  bases  and  bright  red  margins. 

The  ulcer  seems  to  sink  into  the  tissue  and  the  margins  stand  up 
above  the  surrounding  parts.  They  most  frequently  occur  on  the  margins 
of  the  tongue,  inner  surface  of  the  lip  and  cheek. 

They  are  usually  associated  with  an  attack  of  nervous  indigestion, 
but  many  observers  seem  to  be  of  the  opinion  that  they  may  exist,  as  an 
independent  affection.     They  occur  in  young  children's  mouths  very  fre- 


197 

quently,  and  I  have  served  patients  past  the  age  of  forty  that  suffer 
almost  continually  from  them.  The  rapidity  with  which  they  form  is  a 
peculiarity  of  them. 

The  ulcers  are  usually  very  painful  to  the  touch,  making  the  taking  of 
food  difficult,  and  greatly  interfering  with  dental  operations,  when  present 
on  the  lips  or  cheeks.  Young  children  complain  of  the  pain  and  refuse 
to  take  food. 

treatment 

The  local  condition  can  usually  be  benefitted  and  the  painful  ulcer 
entirely  relieved  by  touching  it  with  a  saturate  solution  of  nitrate  of  silver. 
This  remedy  is  so  violently  escharotic  that  care  must  be  taken  not  to  get  it 
anywhere  but  on  the  ulcer,  which  will  soon  present  a  white  coagulated 
appearance.  ■«' 

The  ulcer  should  be  kept  dry  for  a  few  minutes  after  the  application. 
One  painting  is  usually  all  that  is  needed.  An  alkaline  antiseptic  wash 
should  be  prescribed,  and  patient  referred  to  a  physician  for  constitutional 
treatment  if  the  local  conditions  are  at  all  persistent. 

Parasitic  stomatitis  or  thrush,  as  it  is  commonly  called,  is  a  peculiar  ' 
inflammation  of  the  mucous  membranes  of  the  mouth.     It  is  most  com- 
monly seen  in  very  young  children,  and  is   dependent  upon  a  peculiar 
fungus  called  the  saccharomyces  Albicans.     The  fungus  belongs  to  the 
yeast  family  and  has  branching  filaments.      (Fig.  78.) 


Fungus 


Fungus 


Fig.  78. 
Ordium   Albicans    (thrush    fungus).     (Marshall.) 


198 

Osier  says  this  disease  does  not  arise  in  a  normal  mucosa,  but  may 
rapidly  develop  in  unclean  mouths,  especially  when  catarrhal  conditions 
of  the  mucous  membranes  are  present,  and  acid  fermentations  of  food 
remnants  is  permitted  to  occur. 

This  disease  is  not  confined  to  children,  but  is  often  met  with  in  adults 
during  final  stages  of  fever,  chronic  tuberculosis  and  kidney  diseases. 
The  disease  usually  attacks  the  tongue  first,  and  then  rapidly  spreads  to 
all  mucous  surfaces,  and  appears  as  slightly  raised,  pearly  white  spots 
which  gradually  enlarge  and  coalesce. 

The  parasite  develops  in  the  upper  layers  of  the  mucous  membrane, 
and  its  filaments  rapidly  penetrate  the  epithelial  cells,  forming  a  dense  net- 
work which  can  readily  be  scraped  off,  or  if  left  alone  in  a  short  time 'will 
slough  off,  leaving  a  raw,  bleeding,  ulcerating  surface,  differing  entirely 
from  mucous  patches  which  are  confined  to  a  small  depressed  area,  while 
in  thrush,  the  whole  surface  soon  becomes  involved. 

Thave  seen  a  few  cases  where  the  entire  mucous  membrane  on  the 
lips,  tongue,  palate  and  cheeks  were  covered  with  what  appeared  to  be 
a  fuzzy  grayish  white  membrane.  A  few  cases  are  reported  where  this 
disease  has  extended  to  the  soft  palate,  the  throat  and  the  stomach. 

It  is  not  often  that  the  dentist  is  called  upon  to  treat  these  cases,  but 
he  should  be  familiar  with  its  clinical  appearance. 

It  is  epidemic  in  the  spring  and  fall  and  in  babies  it  is  often  the  direct' 
result  of  improper  care  of  nursing  bottles  and  nipples. 

Treatment. — The  child's  mouth  must  be  kept  scrupulously  clean  and 
an  alkaline  wash  used  to  relieve  the  burning  sensation.  A  little  lime 
water  administered  will  often  correct  the  acid  mucous  secretions  and  do 
away  with  the  pain. 

Osier  suggests  the  use  of  a  borax  spray ;  the  phenate  of  soda  is  also 
recommended. 

Sudduth  suggests  the  following  prescription : 

Acidi  Carbolici   3  h  i 

Olei  Gaultherise 3  h  ii 

Olei   Menthse  Peperitae    I  h  iii 

M.  Sig.  Use  as  a  spray. 

In  every  case  the  patient's  general  health  miust  be  looked  after  by  the 
physician,  for  in  these  cases  it  will  usually  be  found  that  the  child's  nutri- 
tion is  poor,  presenting  some  marked  disturbance  of  digestion. 

Gangrenous  stomatitis  (concrum  oris  noma)  is  an  affection  char- 
acterized by  a  rapidly  progressing  grarigrene  usually  beginning  in  the 
gums,  and  soon  extending  to  the  cheek,  rapidly  leading  to  sloughing  and 
destruction. 


199 

It  is  the  most  formidable  disease  of  childhood  and  fortunately  it  is 
"very  rare,  and  is  seen  only  in  children  living  under  most  unsanitary  con- 
ditions or  many  times  during  convalescence  from  severe  acute  fevers.  It 
is  most  frequently  seen  between  the  ages  of  one  to  five  years,  and  is 
more  common  in  girls  than  boys. 

Some  authors  think  it  due  to  some  specific  organism,  but  it  seems 
more  like  a  coagulative  necrosis.  It  usually  attacks  the  gum  high  up  on 
the  buccal  side  of  upper  molar,  and  when  first  seen  the  mucous  membrane 
only  is  affected  but  soon  leads  to  induration  of  all  the  adjacent  tissues  ; 
the  sloughing  extends  and  the  blood  vessels  supplying  the  part  are  soon 
affected  and  the  whole  tissue  of  the  cheek  becomes  hard  and  indurated  and 
filled  with  pus  and  fibrin,  and  soon  the  cheek  is  perforated  and  intense 
inflammation  spreads  rapidly,  and  the  tissues  rapidly  ulcerate  away. 

Severe  constitutional  disturbances  ensue,  the  pulse  rapid,  tempera- 
ture high,  prostration  very  extreme  and  death  within  a  week  usually  from 
perforation  of  a  large  vessel  and  hemorrhage;  the  child  passing  into  a 
comatose  state  passing  away  without  pain. 

The  treatment  of  this  disease  is  usually  unsuccessful.  The  constitu- 
tional conditions  must  be  met.  nourishments  and  tonics  given. 

The  diseased  parts  should  be  burned  with  the  cautery  and  nitric  acid 
applied  to  the  edges  of  the  ulcers,  and  deodorant  antiseptic  lotions  applied 
to  destroy  the  very  fetid  odor  which  is  always  present. 

,When  the  disease  is  recognized  and  treatment  begun  early  recovery 
may  be  hoped  for.  • 

Ulcerative  Stomatitis. 

This  form  of  stomatitis  usually  begins  at  the  free  margins  of  the  gums, 
which  become  red  and  swollen  and  bleed  on  the  slightest  touch.  At  the 
outset  the  mouth  is  hot  and  painful,  and  saliva  flows  freely,  and  the  breath 
is  offensive.  The  glands  are  usually  swollen,  and  also  the  lips;  a  rash 
often  appears  resembling  measles. 

As  the  disease  progresses  ulcers  appear  along  the  gum  margins  of 
both  upper  and  lower  jaws.  At  the  base  of  these  ulcers  is  a  firmly 
adherent  grayish  white  membrane ;  and  in  very  severe  cases  the  edge  of 
the  alveolus  may  become  necrosed  and  the  teeth  loosened. 

It  is  a  disease  that  rarely  proves  fatal,  although  death  occasionally 
results  in  very  debilitated  children.  The  local  treatment  is  to  clean  the 
teeth  and  treat  the  ulcers  with  dilute  chloride  of  zinc,  or  what  is  better, 
the  powdered  chlorate  of  potassium  applied  directly. 

Osier  recommends  the  administration  of  chlorate  of  potassium  in  lo 
grain  doses,  three  times  daily.  Fresh  air,  wholesome  food,  proper  elimina- 
tion, are  the  essential  requirements  as  general  treatment  for  this,  and  all 
other  forms  of  ulcerations  about  the  mouth. 


200 

mercurial  Stomatitis  (Ptyali$m). 

This  is  an  inflammation  of  the  mouth  and  sahvary  glands  caused  by 
mercury.  It  occurs  in  individuals  whose  business  is  associated  with  the 
constant  handling  of  mercury  and  only  rarely  now  as  the  result  of  mercury 
administration. 

Twenty  years  ago  this  disease  was  very  common  when  large  mercury 
dosing  was  frequent  and  even  now  in  an  especially  susceptible  case  mild 
attacks  are  seen,  especially  in  individuals  undergoing  mercury  treatment 
for  specific  disorders. 

It  should  be  said  here  that  individuals  differ  greatly  in  this  regard, 
and  the  susceptible  cases  cannot  be  distinguished  beforehand,  so  that  the 
physician  needs  to  be  on  his  guard  and  watch  for  the  first  signs  of  stoma- 
titis, when  the  drug  should  be  suspended  for  a  time. 

As  soon  as  the  gums  are  touched,  the  drug  should  be  discontinued. 
To  produce  mercurial  ptyalism  it  is  not  necessary  that  large  doses  be  given, 
indeed  many  cases  are  recorded  where  a  dozen  doses  of  calomel  i-io  grain 
four  hours  apart  produced  serious  results. 

Symptoms. 

The  first  mdication  of  this  affliction  is  a  metallic  taste  which  is  soon 
followed  by  swelling  and  redness  of  the  gum  margins,  teeth  become  sore 
and  mastication  difi:icult.  The  saliva  begins  to  flow  freely,  and  by  and  by 
runs  out  of  the  mouth.  The  breath  becomes  foul,  tongue  swollen,  and 
after  a  few  days  ulceration  of  the  gum  margins  appear  and  necrosis  of 
particles  of  the  alveolar  border. 

The  teeth  become  loose  and  in  many  instances  are  lost  or  so  affected 
that  marked  recession  of  the  gum  and  absorption  of  alveolus  results,  which 
so  weakens  the  structures  that  eventually  the  teeth,  are  lost,  and  in  a  few 
instances  necrosis  of  the  lower  jaw  results.  Marshall  reports  only  two 
cases,  both  of  which  proved  fatal. 

treatment. 

The  treatment  must  be  largely  symptomatic.  The  drug  should  be 
discontinued  immediately  or  if  the  affection  has  resulted  from  the  fumes 
while  handling  mercury  the  patient  should  get  away  from  those  surround- 
ings. In  either  case  the  mercury  should  be  driven  from  the  system  by 
the  administration  of  alkaline  waters  in  large  quantities  and  frequent  hot 
baths  given. 

If  there  is  much  salivation  and  accompanying  prostration,  the  patient 
should  be  given  atropine  and  other  supporting  treatment,  liquid  nourish- 
ment should  be  freely  given,  and  if  the  pain  is  severe,  Dovers  powders 
should  be  given. 


201 


The  local  treatment  consists  in  cleaning  the  teeth  and  gums  as  well 

as  possible,  and  an  application  of  chlorate  of  potassium  mouth  wash.     If 

ulceration  appears  astringent  mildly  escharotic  agents  should  be  applied. 

The  case  should  be  watched  for  several  days,  and  if  looseness  of  the 

teeth  appears  the  application  of  iodide  of  zinc  will  be  helpful. 

A  word  should  be  said  here  regarding  the  general  catarrhal  inflam- 
mation of  the  membranes  of  the  mouth,  throat,  and  nose,  which  is  so 
common  in  this  climate. 

In  these  cases  all  the  membranes  are  more  or  less  afifected  and  present 
a  decidedly  reddened  appearance  more  severe  in  some  spots  than  others, 
and  arc  usually  accompanied  by  slight  digestive  disturbances.  Unless 
some  attention  is  paid  to  it  more  severe  forms  may  result. 

The  treatment  consists  in  correcting  the  digestive  disturbances ;  and 
spraying  the  mouth,  throat  and  nose  with  a  carbolic  acid  and  m^enthol 
solution  several  times  a  day  until  relieved. 

Phosphorous  necrosis.— This  subject  does  not  properly  come  under 
the  scope  of  this  book,  and  is  only  presented  because  of  its  similarity  to 
mercurial  stomatitis. 

Phosphorous  necrosis  is  the  result  of  poisoning  from  fumes  of  phos- 
phorous and  is  only  seen  in  the  individuals  who  work  in  match  factories, 
fertilizer  factories  and  the  like. 

Etiology. — There  is  some  difference  of  opinion  as  to  the  exact  mode 
of  attack,  but  the  preponderance  of  evidence  seems  to  prove  that  the 
phosphorous  necrosis  is  the  result  of  local  poisoning  produced  by  the 
fumes  entering  the  tissues  through  some  break  in  the  continuity  of  the 
mouth  structures  whereby  they  get  access  to  the  periosteum  (Marshall), 
and  carious  teeth  seem  to  be  the  most  frequent  route  through  which  the 
fumes  pass  to  the  periosteum. 

Symptoms.— This  affection  usually  begins  to  manifest  its  presence  by 
mild  toothache  and  pain  about  the  jaws ;  soon  the  pain  becomes  severe  and 
.  swelling    starts    and    spreads    rapidly  until  the  entire  face  and    head  are 
involved ;  it  may  affect  one  or  both  sides. 

Abscesses  rapidly  form  and  may  discharge  on  the  face.  The  pus  is 
very  offensive  and  may  exude  around  the  necks  of  the  teeth,  which  soon 
become  loose,  and  small  pieces  of  bone  will  often  work  out  around  the 
gum  margin. '  Sometimes  several  teeth  will  be  retained  in  a  sequestrum  of 
bone,  which  can  readily  be  removed. 

Treatment  consists  of  supporting  the  general  system,  meeting  any 
special  conditions  that  may  arise  and  surgically  treating  the  necrosis. 

Glossitis  and  eczema  of  the  tongue— The  tongue  is  liable  to  the  same 
forms  of  catarrhal  inflammation  as  the  other  soft  tissue  of  the  mouth  and 


202 

throat,  and  the  ■  treatment  must  be  suited  to  each  condition  beside  these 
local  affections.^ 

The  tongue  is  the  index  to  many  disorders  of  the  general  system. 
In  health  it  presents  a  moist,  smooth,  pink  surface,  and  any  change  from 
this  indicates  some  pathological  conditions  not  usually  of  itself,  but  more 
frequently  of  the  general  system  of  which  Sudduth  gives  the  following 
interpretations. 

"A  white  coated  tongue  denotes  febrile  disturbance ;  a  brown  moist 
tongue  indigestion;  a  brown  dry  tongue,  depression,  blood-poisoning, 
typhoid  fever ;  a  red,  moist  tongue,  feebleness,  exhaustion ;  a  red,  dry 
tongue,  inflammatory  fever ;  a  red  glazed  tongue,  general  fever ;  a  tremu- 
lous, moist  and  flabby  tongue,  with  blue  appearance,  tertiary  syphilis. 

"A  moist,  flabby  tongue,  with  the  imprint  of  the  teeth  in  its  sides,  indi- 
cates general  anemia ;  a  pointed  tongue  shows  intestinal  derangement ;  a 
yellow  furred  tongue  indicates  bilious  disorder;  a  moist  tongue  is  a  good 
indication  of  sickness ;  while  a  dry  tongue  represents  the  converse 
condition.^'  ■ 

Glossitis  signifies  inflammation  of  the  tongue.  It  may  be  either 
acute  or  chronic. 

The  acute  form  may  often  be  the  result  of  careless  use  of  dental 
instruments.  Recently  I  attended  an  alarming  case  where  the  tongue 
was  badly  lacerated  as  a  result  of  tooth  extraction.  The  patient  had  been 
put  under  gas  anesthesia  and  accidentally  the  mouth  prop  slipped  out  of 
place  and  the  jaws  closed,  and  the  tongue  was  caught  between  the  teeth, 
resulting  in  cutting  and  tearing  the  tongue  badly ;  infection  resulted,  fol- 
lowed byvery  alarming  symptoms,  several  abscesses  formed  in  the  tissues, 
a  rise  of  temperature  to  104  degrees,  and  almost  total  collapse  from  the 
pain.  The  tongue  was  so  badly  swollen  that  deep  punctures  with  a 
bistoury  were  necessary. 

I  have  also  seen  a  few  cases  where  the  tongue  was  infected  from 
injuries  made  with  broaches,  scalers,  forceps,  etc. 

Treatment. — In  ever}^  case  the  conditions  present  must  govern  the 
treatment.  The  general  elimination  must  be  looked  after,  abscesses 
opened  and  drained,  ulcers  cauterized  and  general  antisepsis  maintained. 
The  tongue  usually  makes  quick  recovery  where  proper  treatment  is 
instituted.  .  : 

eczema  Of  tbe  tongue. 

This  is  a  disease  of  the  tongue  which  is  characterized  by  remarkable 
sloughing  off  of  the  outer  epithelium.  It  usually  begins  in  small  patches 
which  gradually  spread,  uniting  with  one  another,  presenting  an  irregular 
shaped  raw  surface  which  has  been  likened  to  a  geographical  map. 


203 

It  is  usually  accompanied  with  a  good  deal  of  itching  and  burning 
pain.  The  etiology  of  the  disease  is  not  known  and  treatment  consists  in 
frequent  applications  of  solution  of  nitrate  of  silver. 

Ceukoplakia. 

Leukoplakia  buccalis  is  a  subject  that  has  received  considerable  atten- 
tion of  late  from  many  writers.  The  term  leukoplakia  is  derived  from 
the  Greek  and  signifies  white  plates  or  plaques. 

The  affection  is  often  referred  to  as  buccal  psoriasis,  leucoma,  ichthy- 
osis linguate,  smokers'  patches  and  superficial  glossitis. 

Leukoplakia  is  a  chronic  inflammation  of  the  mucous  surface  which 
manifests  itself  in  irregular  thin,  smooth  patches,  white  or  pearly  white 
color,  which  show  no  tendency  to  ulcerate.  The  spots  are  hard  and 
resemble  corns,  indeed  they  are  sometimes  termed  lingual  corns. 

The  ichthyos  variety,  however,  resembles  warts  more  than  corns  and 
are  slightly  raised. 

Location. — The  plaques  most  frequently  appear  on  the  dorsum  of  the 
tongue,  but  many  may  be  seen  on  its  margins  and  all  the  mucous  surfaces 
of  the  m.outh. 

Marshall  reports  several  cases  where  the  beginning  was  on  the 
gingivus,  others  on  edentulous  spaces  in  the  upper  jaw,  and  a  few  on  the 
buccal  gum  of  the  lower  jaw. 

Etiology. — The  etiology  of  leukoplakia  is  not  well  understood  and 
marked  difference  of  opinion  is  expressed  by  different  writers.  Some 
writers  regard  it  as  a  mouth  manifestation  of  psoriasis  and  others  think 
it  a  form  of  skin  disease  resembling  herpes  zoster  or  hives. 

Many  seem  to  regard  it  as  due  to  syphilis,  and  still  others  think  it  is 
a  purely  local  affection  induced  by  smoking  tobacco.  The  bulk  of  evi- 
dence seems  to  point  out  that  this  is  a  distinct  affection,  and  while  it 
resembles  some  mouth  manifestations  of  other  diseases  still  it  does  not 
often  appear  in  connection  with  any  of  them. 

Women  seem  to  be  almost  entirely  free  from  it  so  far  as  I  can  learn, 
and  it  rarely  manifests  itself  in  men  under  twenty-five  and  most  frequently 
about  the  age  of  fifty.  A  little  experience  in  observation  of  these  cases 
will  enable  the  dentist  to  distinguish  these  plaques  from  syphilitic  mucous 
patches. 

The  latter  always  present  a  curdy  grayish  white  appearance  and  are 
slightly  raised  above  the  surrounding  tissue.  Syphilitic  patches  show  a 
tendency  to  ulcerate  and  discharge  a  thin  watery  fluid  and  on  the  surface 
look  like  a  corroded  spot  and  always  yield  readily  to  treatment. 

If  any  doubt  exists  a  short  course  of  mercury  treatment  will  clear 
the  matter  up.  The  dentist  should  be  familiar  with  all  these  mouth 
affections. 


204 

Leukoplakia  plaques  may  extend  in  size  and  become  papillomatous  and 
many  instances  are  recorded  where  genuine  epithelioma  was  developed 
from  them. 

Marshall  calls  special  attention  to  this  affection  for  following  reasons. 

I.  It  is  an  exceedingly  dangerous  affection,  often  being  a  forerunner 
of  carcinoma.  2.  It  is  a  disease  which  from  its  innocent  appearance  and 
the  painless  character  of  its  early  stage  is  seldom  recognized  until  the  dis- 
ease has  progressed  to  a  stage  which  renders  a  favorable  prognosis  exceed- 
ingly doubtful.  3.  The  disease  seems  from  personal  observation  to  be 
on  the  increase.  4.  The  dental  surgeon,  from  the  very  nature  of  his  spe- 
cialty, is  in  a  position  to  see  and  recognize  the  disease  in  its  earliest  stages, 
and  to  warn  the  patient  of  his  condition  before  it  has  progressed  so  far 
as  to  prove  a  menace  to  life. 

The  disease  in  its  earliest  stages  is  much  more  likely  to  come  under 
the  notice  of  the  observing  dentist,  or  stomatologist,  than  of  the  surgeon 
or  the  laryngologist.  As  a  rule  the  patient  does  not  consult  a  surgeon 
until  the  disease  becomes  troublesome ;  it  may  then  have  progressed  so 
far  as  to  give  unmistakable  evidences  of  degenerative  changes  of  a 
malignant  character. 

The  dentist  therefore  should  be  so  familiar  with  the  characteristic 
features  of  the  disease  that  he  could  recognize  it  at  a  glance ;  while  it 
would  be  his  duty  to  impress  upon  the  patient  the  urgent  necessity  of  con- 
sulting an  oral  specialist  with  the  view  of  instituting  measures  calculated 
to  arrest  its  further  development,  or  for  its  complete  extirpation. 

The  causes  of  leukoplakia  seem  not  to  be  well  understood.  Many 
writers  seem  to  think  there  is  always  a  peculiar  thinness  of  the  mucous 
membranes  prone  to  eruption  of  every  sort  and  regarded  as  especially  deli- 
cate. Many  claim  that  chronic  dyspepsia  and  gout  predispose  the  indi- 
vidual to  this  affliction. 

The  exciting  cause  is  charged  to  the  use  of  tobacco,  particularly  the 
pipe  and  cigarettes,  and  the  use  of  undiluted  spirituous  liquors ;  but  any 
constant  irritant  such  as  ill-fitting  plates,  rough  teeth,  large  amount  o£ 
salivary  calculus  may  be  exciting  causes  also. 

treatment. 

This  affliction  does  not  readily  yield  to  treatment,  and  most  authors 
recommend  that  it  be  let  alone,  but  a  few  suggest  the  use  of  a  i  per  cent 
solution  of  chromic  acid  applied  directly  to  the  patch. 

All  sources  of  irritation  should  be  removed.  When  the  spots  take  on 
a  papillomatous  form  they  should  be  surgically  removed.  Many  authors 
recommend  this  procedure  for  all  forms  of  the  disease  as  the  only  means 
of  cure. 


CHAPTER  XIX. 

Oral  in<inife$tmion$  of  $ypl)ili$.    eencral  Considerations. 

Location.     Source  of  Infection.     Diagnosis.     Tlie  Dry  Scaling  Papule.     Pathology. 
Positive  Diagnosis.     The  Secondary  Stages  of  Syphilis.     Secondary 
Eruption.     Treatment.     Tertiary  Syphilis.     Congenital 
Syphilis.     An  After  Word. 


At  the  outset  I  wish  to  say  that  no  description  that  I  can  give  will 
convey  such  accurate  knowledge  of  the  appearance  of  primary  syphilis  as 
can  be  obtained  by  seeing  a  few  cases. 

"Syphilis  is  a  general  infectious  disorder,  both  acc^uired  and  transmis- 
sible by  inheritance,  chronic  in  course,  and  displaying  in  a  determinate 
order  specific  symptoms." — Hyde.  It  is  produced  by  a  specific  micro- 
organism whose  identity  has  not  been  definitely  established. 

The  history  of  the  disease  extends  as  far  back  as  we  have  any  records, 
and  its  ravages  at  the  present  time  are  simply  appalling.  "The  infection  is 
always  conveyed  from  one  to  another  either  by  direct  contact  or  through 
the  medium  of  some  instrument,  utensil  or  other  article  upon  which  it  has 
been  deposited." — Baldwin. 

Before  infection  can  occur  it  is  not  only  necessary  that  the  virus  be 
present,  but  it  must  gain  entrance  to  the  system  through  some  abraded 
surface.  It  cannot  enter  through  the  healthy  skin  or  mucous  membrane, 
but  so  virulent  is  this  disease  that  if  the  virus  does  find  such  an  entrance 
to  the  circulation  syphilis  will  certainly  develop. 

Cocation. 

Next  to  the  genitals  the  mouth  is  the  most  frequent  location  for  the 
primary  lesion,  and  it  is  because  of  this  fact  that  dentists  should  be  very 
familiar  with  its  many  manifestations.  It  has  been  stated  by  several 
syphilologists  that  over  70  per  cent  of  all  extra  genital  chancres  are  found 
in  the  mouth,  tongue,  gums,  tonsils,  avula  and  buccal  mucous  membrane, 
and  of  all  these,  the  lips  and  tongue  are  most  frequently  affected. 

The  most  frequent  modes  by  which  transmission  of  virus  occurs  are 
kissing,  passing  around  smoking  pipes,  using  common  towels  and  hand- 
kerchiefs, drinking  vessels,  knives  and  forks,  blow  pipes,  whistles,  wind- 
instruments,  tooth  brushes,  and,  in  the  case  of  infants,  the  nursing  bottle 
is  a  frequent  source. 

Source  of  Infection. 

The  infectious  material  may  come  from  both  primary  and  secondary 
lesions  and  from  the  blood  of  the  victim.    These  secretions  when  deposited 


206 

on  towels,  etc.,  and  allowed  to  dry  are  still  infectious  during  these 
periods,  but  all  the  other  secretions  of  the  body  are  regarded  as  non- 
infectious, as  is  also  true  of  all  secretions  in  the  tertiary  stage.    _ 

Diagnosis. 

When  infection  occurs  there  is  within  twenty-one  days  a  primary 
sore  developed  which  is  termed  a  chancre.  The  period  of  incubation 
varies  from  six  to  thirty  days.  These  chancres  are  always  single  and 
are  not  auto-inoculable.  They  differ  in  appearance,  each  presenting 
certain  marked  characteristics. 

These  variations  may  depend  on  accidents  attending  inoculation, 
peculiarities  of  the  individual,  or  on  the  particular  tissue  affected.  The 
typical  and  most  usual  form  of  chancres  as  seen  on  the  lip  is  what  is 
known  as  the  Hunterion  or  ulcerating  chancre  (Fig.  79). 


Fig.  79. 

Chancre    of    the    upper    lip. 


(Barrett.) 


In  common  with  most  forms  of  chancre,  this  variety  begins  in  a 
small  papilla,  which  very  soon  sloughs  off  its  apex  and  presents  a  deep 
red  round  or  oval  ulcer.    The  margins  are  usually  elevated  and  very  red. 


207 

while  the  center  is  concave  and  presents  an  ulcerating  appearance  and 
secretes  a  thin  serous  fluid,  and  not  infrequently  this  sore  may  become 
infected  with  pus  or  other  germs,  when  a  mixed  infection  occurs,  result- 
ing in  deceiving  complications.  This  form  is  always  on  the  mucous 
surface. 

Superficial  chancrous  erosion  is  a  form  frequently  met  with  in  the 
mouth.  It  begins  with  a  little  round  or  oval  red  spot,  from  which  the 
epithelium  soon  sloughs  off,  giving  the  appearance  of  a  raw  sore,  which 
is  never  deep  and  presents  a  smooth  surface,  which  occasionally  may  be 
covered  with  a  gray  film,  which  makes  it  easily  mistaken  for  leukoplakia 
or  aphthous  stomatitis. 

The  duration  of  this  form  of  chancre  is  usually  short  and  often  goes 
•unnoticed  until  constitutional  symptoms  appear. 

Cbc  Dry  Scaling  Papule. 

This  variety  begins  in  a  small  dull  red  slightly  elevated  papule, 
which  gradually  elevates  and  turns  purple ;  it  is  hard  to  the  touch.  The 
outer  epithelium  is  soon  lost,  presenting  a  dry  crust.  When  found  in 
the  mouth  is  usually  seen  at  the  junction  of  two  mucous  surfaces,  and 
those  I  have  seen  were  high  up  on  the  buccal  gum  over  the  upper  third 
molar. 

The  incrusted  chancre  is  the  variety  usually  seen  on  the  skin,  and  is 
the  form  usually  seen  when  the  finger  or  other  part  of  the  hand  has  been 
accidentally  infected. 

The  indurated  nodule  is  the  form  usually  seen  at  the  junction- of  the 
skin  and  mucous  membrane,  particularly  of  the  lip.  It-has  a  sharply 
defined  plaque,  or  nodule,  elevated  with  sloping  edges  and  is  dry. 

When  the  primary  sore  appears  on  the  lip,  it  is  most  apt  to  occur 
in  the  fissure  in  the  mnddle  of  the  lower  lip  or  on  the  upper  a  little  to 
one  side  of  the  median  line  (see  Fig.  79).  Of  course  it  may  occur  at 
any  other  abraded  point. 

As  previously  stated,  it  is  the  ulcerating  chancre  that  usually  appears 
on  the  lip  and  presents  a  vermilion  border  with  red  or  grayish  base. 
When  it  occurs  on  the  outside  of  the  lip  it  usually  presents  considerable 
induration,  but  when  within  the  lip  little  or  no  induration.  The  sub- 
maxillary glands  are  always  enlarged. 

When  the  chancre  occurs  on  the  tongue  it  is  usually  flat  or  very 
slightly  elevated,  usually  reddish,  and  when  just  at  the  tip  the  appear- 
ance is  often  as  though  a  piece  had  been  cut  ofif.  It  is  usually  sharply 
defined,  and  can  readily  be  distinguished  from  ordinary  aphthous 
patches  by  its  elevated  border  and  less  concave  center  (Fig.  80)-,-  but 
when  doubt  exists  watch  for  the  enlargement  of  the  suprahyoid  glands.- 


208 


Fig.  80. 

Syphilitic    ulcer    on    the    tongue.    (Black.) 

Patbology. 

The  pathology  of  the  initial  chancre  is  one  of  unusual  interest. 
When  the  virus  is  planted  an  interesting  cycle  of  phenomena  at  once 
begins.  "Here  if  it  finds  favorable  soil  it  grows  and  slowly  increases  till 
its  intrusive  presence  becomes  a  source  of  offence  to  the  tissues  harboring 
it,  and  gradually  inflammatory  reaction  sets  in." — Bronson. 

At  first  it  does  not  appear  that  the  virus  passes  directly  into  the 
circulation,  or  if  it  does  it  is  in  such  small  quantity  that  it  does  not 
make  an  impression,  for  not  until  after  the  chancre  appears  do  we  see 
any  manifestations  of  general  infection. 

The  pathological  changes  in  the  tissues  at  the  point  of  infection,  are 
described  by  Baldwin  as  follows : 

"When  the  poison  of  syphilis  is  deposited  on  an  abrasion  in  otherwise 
healthy  skin,  a  cycle  of  phenomena  at  once  begins.  The  first  manifesta- 
tion of  this  cycle  is  the  infiltration  of  the  tissue  at  the  site  of  infection 
with  small  round  cells,  exactly  as  in  any  inflammation.  With  these 
small  round  cells  are  also  to  be  seen  large  round  or  oval  and  polyhedral 
cells,  filling  up  the  interstices  between  the  meshes  of  the  network  of 
blood  capillaries. 

"At  first  the  blood  vessels  are  involved,  but  by  extension  they  are 
included  in  the  inflammatory  process.  No  connective  tissue  of  a  perish- 
able or  embryonic  type  is  formed.  This  tendency  to  connective  tissue 
formation  is  also  observed  in  the  tertiary  stage  in  lesions  of  the  nervous 
system  due  to  syphilis. 

"The  lymphatic  channels  are  soon  involved  in  the  inflammatory  process, 
and  the  virus,  which  is  either  a  microbe,  or,  as  Otis  suggests,  a  microbe- 
bearing  cell,  is  borne  along  these  vessels  to  the  nearest  lymphatic  glands. 


209 

it  is  deposited,  and  the  same  process  of  inflammation  is  repeated  and  the 
glands  become  swollen  and  indurated.  'First  intuition  virus'  of  infection 
has  traveled.     This  is  the  period  of  first  incubation.'^ 

The  microscopical  changes  are  at  first  those  that  occur  in  all  forms 
■of  local  inflammation.  The  white  blood  cells  flock  to  the  seat  of  infec- 
tion and  are  soon  modified  by  the  action  of  the  virus,  and  it  is  the 
cells  that  carry  the  infection  to  other  parts  of  the  body,  particularly  to 
the  lymphatic  glands. 

Chancroid  is  a  soft  chancre  which  does  not  incur  any  constitutional 
■symptoms.  It  is  of  a  pustular  form  and  its  secretions  are  infectious  and 
also  inoculable,  and  hence  they  are  usually  multiple.  It  is  never  seen  in 
the  mouth  and  causes  no  mouth  lesions,  and  therefore  has  no  special 
interest  to  dentists. 

Positive  Diagnosis. 

I  scarcely  need  remind  the  reader  that  it  is  not  always  possible  to 
distinguish  the  beginning  of  chancre  in  the  mouth  from  many  other 
mouth  lesions,  and  while  I  have  tried  to  point  out  the  distinguishing 
•characteristics  they  are  not  always  an  infallible  guide,  and  even  in  the 
more  advanced  stages  it  is  rarely  wise  to  trust  the  history  obtained  from 
the  patient,  for  they  will  usually  deny  any  knowledge  of  it,  some  be- 
cause they  do  not  know  it  and  others  because  they  wish  to  conceal  it 
from  the  dentist;  and  yet  every  sore  on  the  lips  and  in  the  mouth  should 
not  be  suspected  to  be  of  specific  origin,  and  we  should  be  careful  about 
alarming  patients  by  stating  positive  conditions  until  they  are  positively 
proven. 

Many  of  these  cases  are  first  seen  by  the  dentist,  for  when  the 
primary  sore  appears  in  the  mouth  the  patient  usually  consults  the  dentist, 
thinking  it  to  be  associated  with  some  affection  of  the  teeth. 

The  first  duty  of  the  dentist  is  to  obtain  the  history  of  the  case,  even 
though  in  some  instances  he  may  have  to  listen  to  a  carefully  concocted 
-Story  as  to  how  the  infection  occurred,  that  will  more  than  tax  the  cre- 
dulity of  the  novice. 

To  one  who  has  a  little  experience  these  stories  serve  as  convincing 
proof  of  the  conditions  present.  If  there  can  be  no  definite  history  ob- 
tained then  we  must  wait  the  development  of  positive  proof,  which  if 
not  immediately  seen  in  the  characteristic  appearance  of  the  sore  will  be 
■cleared  up  in  a  few  days  by  the  appearance  of  glandular  enlargements 
and  indurations,  which  ushers  in  the  period  of  second  incubation. 

From  quite  an  extensive  experience  in  handling  syphilitic  cases  in  all 
stages  of  the  disease,  I  find  that  nearly  every  sufferer  is  glad  and  anxious 
to  furnish  you  all  the  information  at  his  command. 


210 

The  treatment  of  the  primary  lesion  is  to  apply  some  form  of  cau- 
tery, usually  nitric  acid,  nitrate  of  silver  or  chromic  acid,  but  the  most 
important  thing  is  to  clean  the  mouth  and  put  the  patient  in  the  hands  of 
a  competent  specialist,  who  will  put  him  through  a  thorough  course  of 
treatment  which  will  eventually  drive  the  virus  from  the  system. 

This  treatment  consists  in  the  use  of  mercury  and  potassium  salts, 
which  are  pushed  to  the  limit  of  tolerance,  each  alternating  with  the 
other.  This  disease  is  considered  very  amenable  to  treatment,  but  it 
requires  from  two  to  five  years  to  accomplish  a  cure,  which  cannot  even 
then  be  considered  permanent  or  positive. 

Cbe  Secondary  Stages  of  Syphilis. 

While  the  primary  manifestations  of  syphilitic  infection  is  in  a  local 
lesion  or  chancre,  sooner  or  later  distinct  signs  appear  which  show  that 
the  whole  system  is  being  infected.  These  signs,  which  are  at  first 
scarcely  noticeable,  become  pronounced  toward  the  end  of  what  is  known 
as  the  second  incubation  period. 

"In  distinction  from  all  other  known  infectious  diseases,  syphilis 
has  a  second  period  of  incubation,  by  which  is  meant  the  time  elapsing 
between  the  advent  of  the  so-called  secondaries — a  generalized  eruption 
and  its  concomitants." — Ziesler. 

The  secondary  manifestations  of  syphilis  begin  to  appear  about  the 
fourth  week,  although  it  should  be  stated  that  sometimes  they  appear 
in  twelve  days,  and  occasionally  they  never  appear,  the  patient  skipping 
periods  of  several  years,  when  the  tertiary  or  third  stage  may  appear. 

The  secondary  manifestations  are  usually  ushered  in  by  a  short 
period  of  fever  and  fatigue  and  headache,  particularly  over  the  frontal 
region.  As  soon  as  the  initial  sore  has  taken  root  there  is  some  general 
morphological  changes  in  the  blood  and  the  glands  in  the  neighborhood 
become  indurated,  especially  the  small  glands  about  the  neck  and  behind 
the  ears ;  they  attain  the  size  of  small  peas. 

It  is  probable  that  the  virus  is  carried  throughout  the  system  through 
both  the  lymph  and  blood  vessels.     The  hair  begins  to  fall. 

Secondary  eniption, 

,  The  recognition  of  the  secondary  eruption  is  very  important  because 
it  not  only  confirms  the  diagnosis,  but  its  secretions  are  also  infectious, 
and  the  mucous  patches  which  usually  develop  are  most  frequently  the 
source  from  which  infection  is  disseminated. 

These  eruptions  begin  in  the  form  of  a  rash  known  as  syphilides,  and 
which  assume  every  variety  of  form  that  the  nature  of  the  skin  and 
mucous  membrane  will  permit. 


311 


Syphilides  are  always  situated  in  the  papillary  layer  of  the  skin,  and 
appear  at  different  parts  of  the  body;  they  have  their  beginning  in  a 
kind  of  roseola  or  skin  redness  over  the  abdomen,  front  of  the  leo-s, 
back  of  the  neck  and  scalp. 


Fig.  81.  '  ' 

.Syphilides  on 'the  face.     (Fox.) 

The  face  is  not  so  often  affected  except  in  the  more  severe  forms 
(Fig.  8i).  The  mucous  membranes  of  the  mouth  are  often  affected. 
These  syphilides  may  present  in  any  or  all  of  the  following  forms :  erythe- 
matous (red  blotches),  copper  colored  spots,  scaly  spots,  vesicular  pimples, 
tubercular  nodules,  rupial  or  crusty  form ;  all  of  these  forms  may  exist  on 
the  same  subject  and  many  intermediate  forms  as  well.  The  first  mani- 
festation in  the  mouth  of  this  secondary  stage  is  the  presence  of  erythe- 
matous spots  all  over  the  palate  and  fauces. 

In  the  mouth  the  mascular  copper  colored  spots  are  frequently  seen ; 
they  occur  on  the  tongue,  hard  and  soft  palate,  mucous  membrane  of  the 
cheek,  and  especially  underneath  the  tongue  in  the  mucous  membrane 
folds. 

The  papular  form  begins  as  a  reddish  pimple  on  the  skin,  but  in  the 
mouth  as  an  erosion  and  not  as  a  pure 'type.  They  are  situated  in  the 
submucous  structures  and  present  the  appearance  of  a  raw  sore  with 
sharply  defined  edges  which  are  slightly  raised,  sinking  in  the  center.  The 
bottom  may  be  red  or  slightly  yellowish,  the  discharge  is  not  great,  but 
it  is  regarded  by  syphilologists  as  the  most  infectious  of  all  the  secondary 
mouth  lesions. 


212 

The  other  variety  of  syphilides  with  which  the  dentist  has  most  to 
do  is  known  as  mucous  plaques  or  mucous  patches.  They  are  most  fre- 
quently seen  on  the  border  of  the  tongue,  the  inside  of  the  cheek  or  inner 
surface  of  either  lip. 

In  general  appearance  they  resemble  the  ordinary  aphthous  patches 
"which  are  so  frequently  seen,  and  which  have  been  spoken  of  in  the  pre- 
ceding chapter.  Syphilitic  mucous  patches  assume  two  forms,  one 
■erosive,  with  a  moist,  brownish  red  surface,  with  decided  hypertrophy 
around  its  margins ;  under  the  finger  they  are  hard  and  are  warty  in 
appearance. 

The  other  form  present  is  milky  white  secreting  center,  which  is 
somewhat  depressed,  surrounded  by  a  red  elevated  margin ;  the  secretions 
are  foul  smelling  and  infectious.  The  number  of  these  patches  present 
in  the  mouth  of  a  given  case  depends  somewhat  on  personal  uncleanli- 
ness,  decayed,  rough  teeth,  using  hot  foods,  alcoholic  beverages  and 
tobacco  smoking. 

treatment 

The  treatment  of  these  mucous  patches  is  very  important,  for,  as 
stated,  the  secretion  from  them  is  very  infectious.  In  addition  to  the  proper 
mercury  course  each  ulcer  should  be  cauterized  with  nitrate  of  silver,  or 
chromic  acid  lo  drch.  to  the  ounce,  and  suitable  germicidal  mouth  wash 
prescribed  and  all  sources  of  irritation  removed. 

tertiary  $yt>bili$. 

While  the  tertiary  form  of  syphilis  usually  follows  the  secondary 
stages  it  does  not  always  develop.  Many  cases  are  terminated  by  proper 
treatment  and  no  tertiary  symptoms  appear. 

The  second  and  third  stages  may  be  merged  into  one  and  many 
authorities  consider  the  third  stage  only  the  sequelae  of  the  other  forms 
and  not  true  syphilis ;  but  be  that  as  it  may,  the  fact  is  that  this  form 
usually  follows  the  other,  and  is,  strictly  speaking,  the  destructive  stage. 

This  stage  is  usually  manifested  by  more  or  less  rapid  destruction 
of  both  hard  and  soft  tissue,  and  is,  strictly  speaking,  an  ulcerative  proc- 
ess, in  which  the  tendency  is  to  eat  deeply  into  the  tissue  and  spread  in 
all  directions.  Fig.  82  represents  a  case  in  which  a  hole  was  eaten 
through  the  hard  palate. 

This  stage  usually  begins  with  the  appearance  of  tubercles  or  super- 
ficial gumma,  which  appears  in  skin  and  mucous  surfaces,  and  as  time 
goes  on  the  deeper  structures  are  involved  and  the  surface  begins  to  eat 
away. 

Gummata  are  often  seen  in  the  mouth,  particularly  on  the  tongue 
(Fig.  83).    They  usually  begin  as  a  collection  of  small  round  spots,  which 


^K\ 


Fig.  S3. 

Syphilitic   ulceration    of   hard   and  soft   palate.      (Marshall.) 


Fig.  83. 
Gumma— toad's   back  appearance   of  tongue   in   syphilis.      (Wende.) 


214 

seem  to  pain  and  soften,  and  finally  break  down  and  begin  their  peculiar 
process  of  ulceration,  which  gradually  spreads  to  all  the  adjacent  tissues. 

The  margins  of  these  ulcers  are  usually  irregular,  overhanging,  and 
often  small  pieces  of  soft  tissue  will  be  cut  off  and  float  away.  The 
secretions  from  these  ulcerating  surfaces,  while  exceedingly  foul  smelling, 
is  not  infectious. 

The  dentist  is  not  called  upon  to  treat  the  latter  stages  of  this  affec- 
tion, and  yet  a  knowledge  that  will  enable  him  to  recognize  it  at  sighr 
is  important,  for  during  this  stage  no  serious  operation  should  be  under- 
taken, especially  if  it  contemplates  the  cutting  or  lacerating  of  tissue  to 
any  extent ;  even  the  extraction  of  a  tooth  often  leaves  a  wound  that  is 
very  slow  to  heal. 

The  temptation  to  cut  the  gummata  is  very  great  unless  one  recog- 
nizes their  character. 

eongenital  $ypl)i1i$. 

It  is  a  lamentable  fact  that  this  disease  is  hereditary  and  that  so 
many  infants  are  born  into  the  world  with  a  syphilitic  taint. 

The  disease  may  be  transmitted  to  the  offspring  by  either  father  or 
mother,  and  the  father  may  transmit  it  without  infecting  the  mother. 
Many  times  the  disease  proves  fatal  to  the  fetus,  and  more  often  the 
child  dies  soon  after  birth ;  but  there  are  many  cases  where  the  taint  is 
not  shown  until  considerably  later  in  life. 

It  always  begins  in  the  tertiary  form,  and  is  therefore  not  infectious, 
and  in  this  connection  it  should  also  be  said  that  it  is  very  much  more 
resistant  to  treatment  than  when  acquired. 

It  usually  manifests  its  presence  by  a  peculiar  erythematous  rash, 
although  often  at  birth  there  may  be  other  unmistakable  signs  such  as 
cracks  in  the  lips  and  fissures  in  the  tongue,  rough  nails,  cleft  palates  and 
other  indications  of  faulty  development, 

Hutchinson's  teeth  are  no  longer  considered  signs  of  syphilis,  but 
rather  signs  of  some  disturbance  of  nutrition  during  the  period  of  tooth 
formation.  If  none  of  these  signs  appear  during  the  first  year  the  anxious 
parents  may  feel  quite  certain  that  their  child  has  escaped  the  taint. 

m  Hftcr  Ulord. 

Syphilologists  have  discovered  that  they  can  push  the  mercury  treat- 
ment safely  and  to  a  much  farther  extent  without  danger  of  salivation 
and  necrosis;  when  the  mouth  is  in  a  healthy  condition,  so  that  it  has 
become  a  custom  among  them  to  first  send  these  syphilitic  cases  to  the 
dentist  that  his  mouth  may  be  put  in  order,  particularly  relating  to  thor- 
ough cleansing  of  teeth  and  gums. 

Many  of  these  cases  apply  to  the  dentist  before  they  do  to  the 
physician  because,  as  stated  before,  they  often  think  the   initial  mouth 


215 

lesion  due  to  some  disorder  associated  with  the  teeth ;  the  dentist,  there- 
fore, should  be  able  to  recognize  the  condition,  and  after  putting  the 
mouth  in  order  as  to  cleanliness,  the  patient  should  be  directed  to  a 
competent  specialist. 

In  this  regard  it  should  be  stated  that  only  temporary  work  in  the 
way  of  fillings  is  attempted  until  the  proper  course  of  treatment  has  been 
carried  through  by  the  physician. 

Crowns  and  bridges  and  all  work  of  that  nature  is  not  attempted. 
Dentists  must  use  every  precaution  in  handling  these  cases,  both  in  regard 
to  avoiding  infecting  themselves  through  sores,  scratches,  hangnails  or 
any  kind  of  abrasion  on  the  hands  ;  and  when  cleaning  teeth  avoid  specks 
of  tartar  or  debris  flying  into  the  eye. 

The  care  of  instruments  is  spoken  of  in  Chapter  XIII,  to  which  the 
reader  is  referred.  I  ask  the  reader  to  familiarize  himself  with  this  dis- 
ease ;  learn  to  recognize  it  at  a  glance  by  observing  well  understood  cases, 
many  of  which  can  be  found  in  almost  every  hamlet. 

That  the  dental  profession  is  sadly  ignorant  of  the  manifestations  of 
this  disease  cannot  be  denied. 

That  many  operators  work  day  in  and  day  out,  utterly  careless  of 
the  dangers  of  carrying  this  virus  from  one  mouth  to  other  mouths,  or 
of  infecting  themselves,  is  equally  true. 

From  the  facts  I  have  tried  to  present  regarding  this  disease  it  must 
appear  to  be  of  very  serious  importance  to  the  dental  profession,  for  how 
culpable  is  the  operator  who  unwittingly  or  even  through  ignorance  of 
its  nature  infects  an  innocent  human  being  with  this  most  awful  malady, 
a  disease  which,  though  now  considered  amenable  to  treatment,  always 
leaves  in  its  wake  not  only  death,  but  living  destruction,  shame,  loath- 
someness, rottenness,  paralysis,  and  horrible  markings  to  untold  thousands 
of  the  best  families  of  our  country. 


CHAPTER  XX. 


Diseases  of  tbe  IDdxillary  Sinus. 

Empyema.     Etiology.     Symptoms  and  Diagnosis.     Treatment.     Ulcers.     Necrosis, 
Causes.     Treatment.     Tumors. 


The  maxillary  sinus,  or  antrum  of  Highmore,  is  a  triangular  shaped 
cavity  contained  within  the  body  of  the  superior  maxillary  bone.  It  has 
a  natural  opening  into  the  nose  through  which  the  normal  secretions 
pass,  and  is  lined  with  a  mucous  lining  which  is  analogous  to  the  schnei- 
derian  membrane  of  the  nose. 

This  membrane  is  covered  with  ciliated  cells  so  arranged  that  in, 
normal  action  they  carry  the  secretions  out  through  the  opening  into  the 
nose.  This  opening  is  not  at  the  most  dependent  part  of  the  antrum,  and 
hence  this  provision  of  nature. 

The  floor  of  the  antrum  is  immediately  over  the  apices  of  the  roots 
of  the  posterior  teeth,  and  in  many  specimens  examined  the  floor  is  con- 
voluted, each  little  eminence  being  over  a  root  apex. 

Antrums  dififer  both  as  to  size  and  shape ;  in  some  cases  its  anterior 
wall  is  as  far  forward  as  the  cuspid  root  apex ;  in  others  it  does  not  come 
forward  to  the  second  bicuspid. 

Most  antrums  are  divided  into  two  or  more  chambers  by  thin  bony 
partitions  arising  from  the  floor  to  about  one-quarter  the  height  of  the 
sinus,  and  many  cases  have  no  divisions.  The  antrum  serves  as  a 
sounding  board  for  the  voice. 

Diseases  of  the  antrum  are  very  common,  more  so  than  formerly, 
especially  among  the  lower  classes ;  and  climatic  conditions  have  much  to 
do  with  its  prevalence  in  certain  localities,  and  certain  constitutional 
conditions  have  much  to  do  with  these  diseases. 

The  diseases  of  the  antrum  can  be  divided  into  four  general  classes. 

First — Empyema,  a  suppurative  inflammation. 

Second — Ulcerations  of  its  mucous  lining. 

Third — Necrosis  of  some  portion  of  its  walls. 

Fourth — Tumors.  The  last  two  requiring  essentially  surgical 
treatment. 

Empyema. 

Empyema  of  the  antrum  is  a  purulent  inflammation  affecting  the 
antrum. 


217 

etiology. 

Empyema  often  has  its  source  in  acute  or  chronic  catarrhal  inflamma- 
tion, which  may  come  from  the  nasal  cavity  on  account  of  its  close  prox- 
imity. Inflammation  of  the  membranes  of  the  nose  may  result  in  partial 
or  complete  closure  of  the  natural  antral  opening,  and  as  a  consequence 
stagnation  of  its  fluid  contents,  which  in  time  may  become  infected  witli 
pyogenic  germs,  resulting  in  suppurating  inflammation,  with  breaking 
down  of  the  lining  membrane.    This  is  probably  the  most  common  cause. 

Another  point  that  should  be  mentioned  here  which  may  act  as  a 
causative  factor,  and  that  relates  to  the  fact  that  sometimes  the  secretions 
of  the  frontal  sinus  and  the  ethmoid  cells,  instead  of  discharging  through 
the  infundibulum  into  the  middle  meatus  of  the  nose,  discharge  directly 
into  the  antrum.     This  fact  was  pointed  out  by  Cryer. 

Abscessed  teeth  are  a  frequent  cause  by  discharging  pus  into  the 
antrum.  The  presence  of  foreign  substances  such  as  roots  of  teeth  that 
have  accidentally  been  forced  there  in  extracting.  Malposed  teeth  have 
been  found  erupting  into  the  antrum. 

Symptoms  and  Diagnosis. 

The  symptoms  of  this  form  of  antrum  disease  are  sometimes  mis- 
leading, particularly  if  the  case  is  one  of  chronic  slow  suppuration,  when 
the  discharge  will  often  not  be  noticed.  In  the  great  majority  of  cases 
there  will  be  an  offensive  odor,  a  feeling  of  fullness,  a  discharge  into  the 
nose  when  lying  on  the  opposite  side  of  the  face,  or  in  very  acute  cases^ 
where  suppuration  is  rapid  and  opening  partially  closed,  there  will  be 
severe  pain  and  swelling,  pain  often  in  the  eye,  and  occasionally  pus  dis- 
charging into  the  mouth  through  a  sinus  in  alveolus  where  tooth  had 
recently  been  removed. 

Examination  through  the  nose  by  use  of  nasal  speculum  and  probing 
needle  pus  or  other  purulent  fluids  can  be  extracted.  Trans-illumination 
will  sometimes  assist. 

treatment. 

The  treatment  of  the  usual  engorgements  of  the  antrum  where  there 
is  no  pus  or  local  lesion  is  very  simple.  It  consists  in  reopening  the 
natural  opening  into  the  nose  and  expanding  it  with  a  trocar  or  inserting 
a  piece  of  tubing  to  allow  free  drainage  and  douching  with  warm  normal 
salt  solutions.  A  few  treatments  will  usually  suffice  if  the  nasal  condi- 
tions are  attended  to. 

In  severe  suppurating  cases  it  is  always  best  to  secure  an  artificial 
opening;  it  is  best  to  make  this  opening  into  the  mouth  because  it  can  be 
made  in  the  most  dependent  part  of  the  sinus,  and  is  more  easy  of  access 


2l8 

and  consequently  better  drainage.  I  have  never  had  any  success  in  treat- 
ing these  cases  through  the  nasal  cavity,  although  some  recommend  that 
method. 

If  the  first  molar  is  missing  it  is  easiest  to  make  the  opening  through 
its  socket.  If  all  the  teeth  are  present  then  I  like  Dr.  Gilmer's  plan  of 
opening  above  the  mesio-buccal  root  of  the  first  molar,  where  the  cheek 
will  close  it  and  keep  food  out. 

A  small  opening  is  all  that  is  needed  at  first,  although  it  must  l)e 
large  enough  to  furnish  ready  drainage.  The  antrum  should  then  be 
irrigated  with  copious  quantities  of  normal  salt  solution,  repeating  every 
day  for  a  week,  when  recovery  will  result  in  the  simple  cases;  but  if 
considerable  foul  smelling  pus  be  present  then  more  radical  measures 
are  necessary. 

In  these  bad  cases  I  usually  proceed  as  above  for  a  treatment  or  two, 
then  if  pus  continues,  I  make  a  large  enough  opening  to  place  the  small 
electric  bulb  inside  the  antrum  to  light  it  up,  and  not  only  explore  with  an 
instrument  but  with  the  finger. 

Sometimes  the  bony  partitions  may  have  to  be  broken  down,  and  of 
course  if  there  is  any  dead  necrotic  tissue  it  should  be  removed  and  the 
lining  carefully  curetted,  and  all  flushed  with  normal  salt  solutions  and 
borax  water  with  cinnamon  and  carbolic  acid.  After  irrigating  freely  the 
sinus  should  be  packed  with  iodoform  gauze. 

Irrigation  and  repacking  should  be  repeated  every  few  days  accord- 
ing to  conditions  until  all  pus  ceases.  In  cases  of  violent  pus  formation, 
I  use  I  per  cent  chinosol  solution  as  a  final  douche  and  pack  chinosol 
gauze  a  time  or  two. 

In  addition  to  this  the  patient  should  use  solution  of  Siler's  antisep- 
tic nasal  tablets  with  which  to  douche  the  nose  twice  daily.  It  is  some- 
times advisable  to  use  a  gutta-percha  plug  to  keep  the  opening  from 
closing.  This  can  usually  be  kept  in  place  by  clasping  it  to  an  adjoining 
tooth. 

Ulcm. 

Ulcerations  are  usually  the  result  of  some  constitutional  disturbance 
and  usually  affect  the  mucous  lining  of  the  nose  and  mouth.  The  only 
ulcerations  of  serious  moment  are  associated  with  syphilis,  which  some- 
times destroys  not  only  the  linings  but  periosteum  and  bone. 

The  treatment  must  be  constitutional,  using  those  remedies  Indicated 
for  tertiary  syphilis.  The  local  treatment  consists  in  keeping  the  parts 
clean. 

It  is  sometimes  difficult  to  make  these  artificial  openings  close  per- 
fectly.   In  several  cases  I  have  scarified  the  edges  and  sutured  together. 


219 

necrosis. 

Necrosis  of  any  of  the  walls  of  the  antrum  is  a  possibility,  but  I 
have  never  seen  any  except  those  involving  the  floor  and  outer  wall. 

Causes. 

Necrosis  may  result  from  the  same  variety  of  causes  as  that  occurring- 
in  the  other  portion  of  the  body,  but  most  commonly  from  inflammation 
of  the  periosteum  as  a  result  of  some  disease  associated  with  the  teeth 
or  traumatic  injuries. 

Alveolar  abscess  may  result  in  alveolar  necrosis  involving  the  floor 
of  the  antrum,  and  the  outer  wall  may  be  destroyed  as  a  result  of  pus 
poisons  in  the  antral  cavity. 

treatment. 

In  either  case  if  a  sequestrum  has  formed  the  necrotic  bone  should 
he  surgically  removed  and  treatment  instituted  the  same  as  for  empyema. 
There  Is  one  additional  point  which  relates  to  holding  the  contour  of  the 
face  after  outer  wall  is  destroyed.  This  is  usually  done  with  antiseptic 
wax  or  gauze  packing  until  such  time  as  nature  can  supply  the  needed 

bone. 

tumors. 

Tumors  of  the  antrum  may  occur  in  every  variety,  but  most  com- 
monly as  polypi  and  other  mucous  cysts.  They  are  usually  very  vascular, 
usually  arising  from  the  floor,  and  rarely  attain  such  size  as  to  cause 
serious  trouble,  although  some  authorities  claim  they  are  malignant  in 
their  tendencies.  The  treatment  is  a  radical  surgical  one,  in  which  a 
generous  opening  into  the  antrum  must  be  made  either  through  the 
nasal  or  outer  wall,  through  which  the  tumor  can  be  thoroughly  removed, 
and  after  treatment  similar  to  that  already  described. 


CHAPTER  XXI. 

matiiigement  of  tbe  Diseases  of  ehMtzWs  Ceetb. 

Dentition.     Pathology.     Treatment.     The  Diseases  of  Deciduous  Teeth,  and  Soft 

Tissues  of  the  Mouth.     Diseases  of  the  Pulp.     Putrescent  Cases.     Root 

Filling.     Sensitive  Dentine.     Cleaning  Teeth.     Management  of 

Permanent  Teeth  During  Childhood.     Management 

of  Sensitive   Cases. 


The  pathology  and  therapeutics  of  the  diseases  common  to  children's 
teeth  can  most  easily  be  presented  under  three  heads. 

1.  Those  diseases  incident  to  the  process  of  teething. 

2.  The  diseases  of  the  deciduous  teeth  and  soft  tissue  before  the 
permanent  set  are  erupted. 

3.  The  care  of  permanent  teeth  during  childhood. 

Dentition. 

Dentition  may  be  defined  as  the  process  of  teething;  it  is  the  physio- 
logical process  of  supplying  the  infant  with  teeth.  The  process  may  be 
said  to  begin  when  the  crown  of  the  tooth  has  formed  and  begins  to 
pass  through  the  bony  covering  in  which  it  is  held. 

It  must  be  remembered  that  the  early  calcifying  tooth  is  contained 
in  a  bony  crypt  which  is  separated  from  the  bone  of  the  jaw  by  vascular 
tissue  on  all  sides.  In  the  lower  jaw  the  floor  of  the  crypt  rests  imme- 
diately over  the  inferior  dental  canal,  and  in  the  upper  jaw  it  rests  over 
the  infraorbital  canal. 

The  covering  of  the  crypt  is  a  thin  layer  of  bone  which  forms  the 
outline  of  the  alveolus.  It  can  readily  be  seen  then  that  the  roots  cannot 
form  until  the  crown  passes  toward  the  surface  away  from  the  canals 
in  the  jaw. 

The  bone  over  the  crypt  is  slightly  fissured  to  facilitate  absorption 
and  make  the  passing  through  of  the  tooth  crown  easier.  As  the  crown 
passes  through  this  bone  the  roots  begin  to  develop  and  continue  until 
some  little  time  after  the  tooth  crown  has  assumed  its  position  in  the 
mouth. 

While  this  is  going  on  there  is  gradually  forming  an  alveolar  wall 
which  is  to  make  the  tooth  socket.  This  is  the  method  by  which  all  the 
teeth  develop  and  take  their  places  in  the  arch,  both  upper  and  lower. 

It  does  not  seem  to  come  within  the  province  of  this  article  to  pre- 
sent data  regarding  the  time  of  eruption  and  calcification  of  the  various 


221 

teeth,  which  can  be  learned  by  referring  to  books  on  dental  anatomy. 
What  we  are  interested  in  now  is  the  diseases  associated  with  the 
process  of  dentition. 

While  the  process  of  tooth  erupting  is  physiological  it  is  nearly 
always  associated  with  disturbances  which  are  pathological.  The  process 
by  which  the  tissues  over  the  erupting  tooth  are  forced  out  of  the  way 
is  one  of  resorption  under  pressure. 

The  teeth  cusps  act  as  the  irritant  which  produces  the  stimulus  to 
the  resorption  process,  and  consequently  the  tissues  must  in  themselves 
be  tender  and  a  source  of  considerable  pain. 

A  glance  at  the  tissues  will  reveal  the  hyperemic  condition  present, 
which  as  the  tooth  presses  through  the  gum  tissues  often  becomes  in- 
flammatory. The  pressure  on  the  nerve  filaments  must  be  a  source  of 
considerable  pain.  The  parts  become  hot,  which  is  shown  by  the  infant's 
desire  to  bite  on  something  cold. 

It  is  doubtless  true  that  the  desire  to  bite  things  is  an  effort  of  the 
child  to  relieve  the  pressure  irritation,  and  yet  it  seems  to  be  a  pro- 
vision of  Nature  by  which  the  gum  is  forced  out  of  the  way  of  the 
erupting  teeth,  and  hence  the  value  of  the  ivory  or  silver  ring,  which 
can  be  kcDt  clean,  and  affords  a  means  by  which  the  infant  may  aid 
nature. 

So  long  as  the  process  does  not  exceed  the  bounds  of  a  reasonable 
physiological  process  very  little  disturbance  results ;  but  when  either 
from  the  density  of  the  tissues  or  other  complicating  circumstances  such 
as  faulty  nutrition  the  normal  process  is  interfered  with,  then  we  often 
have  a  train  of  consequences  which  may  even  seriously  endanger  the 
life  of  the  infant. 

When  we  remember  that  the  nerve  which  supplies  these  tissues  is 
the  fifth  cranial  nerve,  and  that  this  is  the  largest  and  most  sensitive  of 
all  the  nerves,  and  that  these  tissues  are  so  intimately  associated  with 
the  great  sympathetic  system,  we  can  readily  see  why  such  grave  dis- 
turbances occur. 

Coupled  with  this,  also,  is  the  fact  that  at  this  period  of  life  the 
spinal  system  predominates  the  system.  Then,  again,  the  mucous  lining 
of  the  mouth  and  tongue  are  in  such  close  proximity  to  the  throat,  oeso- 
phagus and  stomach,  that  the  affection  of  the  mouth  can  readily  spread 
to  these  organs,  which  are  necessarily  sensitive  to  environment. 

When  we  take  all  of  these  things  into  consideration  we  can  see  a 
rational  explanation  why  sometimes  such  serious  disturbance  may  be 
rightly  attributed  to  faulty  dentition.  However,  I  am  quite  convinced 
that  much  mischief  is  laid  at  the  door  of  erupting  teeth  which  does  not 
rightly  belong  there,  but  which  for  lack  of  better  understanding  of  the 


222 

real  cause  can  easily  be  explained  to  the  satisfaction  of  mothers  by  say- 
ing, "your  baby  is  teething." 

Patbolegy. 

The  first  indication  of  teething  is  seen  in  the  increased  flow  of  saliva. 
This  "drooling"  is  due  to  irritation  of  the  fifth  nerve,  which  in  turn 
afifects  the  salivary  glands  through  another  of  its  branches.  This  is  evi- 
dently a  plan  of  nature  to  cool  and  keep  moist  and  clean  the  parts. 

The  next  indication  is  the  cheek  eruptions,  which  are  doubtless  re- 
flex in  origin,  Sometimes  this  takes  the  form  of  mucous  ulcers,  which 
are  sore  and  must  cause  a  degree  of  pain  and  restlessness.  The  child 
usually  becomes  wakeful  and  peevish,  and  if  the  gums  become  severely 
inflamed  cries  and  displays  "fits  of  temper."  If  several  delayed  teeth 
are  erupting  at  the  same  time  and  the  consequent  local  condition  unusu-, 
ally  severe,  diarrhoea,  colic  and  even  convulsions  may  develop. 

Miller  points  out  that  the  germs  which  cause  infant  diarrhoea  are 
usually  found  in  the  mouth,  by  which  route  they  probably  enter.  I  should 
add  here  that  frequently  carelessness  about  sterilizing  nursing  bottles  and 
nipples  is  responsible  for  many  serious  mouth  affections. 

In  examining  the  mouth  of  an  infant  in  such  distress  the  thing  to 
look  for  is  evidence  of  severe  active  inflammation  over  the  region  where, 
according  to  the  age,  the  tooth  should  erupt,  and  then  such  other  sore 
places  as  can  be  found. 

treatment 

If  severe  localized  inflammation  presents  then  the  thing  needed  is  the 
lancet  used  under  antiseptic  precautions.  It  is  not  so  much  to  remove  the 
o-um  over  the  tooth  (although  it  is  as  well  to  cut  deep)  as  to  let  the  con- 
o-ested  blood  out  that  the  lancet  is  used.  The  accompanying  illustration 
will  indicate  the  best  method  of  lancing  (Fig.  84). 


Fig.  84. 

Showing  method  of  lancing  gums  over  erupting  teeth.     (Burchard.) 

Care  must  be  taken  to  hold  the  infant  securely  and  guide  the  lancet 
so  as  to  avoid  all  danger  of  slipping  and  doing  serious  damage  to  adjacent 
parts. 


223 

The  parts  should  be  carefully  sponged  with  a  boric  acid  solution  and 
the  constitutional  disturbance  attended  to  by  the  physician. 

ZM  Diseases  of  Deciduous  teetb,  and  Soft  tissues  of  the  mouth. 

The  care  that  the  temporary  teeth  receive  has  much  to  do  with  the 
value  of  the  permanent  set,  both  in  relation  to  their  formation  and  posi- 
tion in  the  arches.  The  child  should  be  brought  to  the  dentist  early  in 
order  that  its  teeth  may  be  examined  and  whatever  treatment  necessary 
given,  and  wholesome  instruction  given  both  parent  or  governess 
and  the  child. 

The  objects  of  caring  for  the  deciduous  teeth  are  three:  First,  that 
they  may  be  preserved  to  do  necessary  mastication  until  permanent  teeth 
erupt;  second,  that  the  normal  process  of  development  may  prepare  the 
way  for  normal  occlusion  of  the  permanent  set,  and  third,  that  the  child 
may  avoid  a  series  of  painful  conditions  which  will  result  in  severe  opera- 
tions and  consequent  everlasting  dread  of  the  dental  chair. 

The  dentist  should  do  all  he  can  to  correct  the  false  notion  in  the 
minds  of  parents  that  these  teeth  are  unimportant  because  temporary. 

There  is  another  point  in  this  connection  and  that  relates  to  the  cul- 
tivation of  good  hygienic  mouth  habits,  which  once  established  will  con- 
tinue through  life,  and  also  the  development  of  that  friendship  between 
dentist  and  child  which  will  entirely  do  away  with  that  awful  dread  of 
the  dentist  and  dental  operations  which  so  many  experience. 

Diseases  of  tbe  Pulp. 

Temporary  teeth  are  subject  to  all  the  diseases  common  to  the  per- 
manent, but  in  a  modified  form. 

Hyperemia  of  the  pulp  results  from  the  same  causes,  but  It  rarely 
produces  such  severe  pain.  This  is  accounted  for  by  the  fact  that  the 
canal  has  usually  begun  to  enlarge  by  resorption  before  such  conditions 
arise  and  also  the  lymphatic  connections  are  better. 

The  treatment  must  always  be  palliative.  The  carious  cavity  should 
be  cleansed  as  well  as  possible  of  all  loose  material  and  anything  pressing 
on  the  pulpal  wall  removed,  after  which  the  cavity  should  be  dried  and  an 
application  of  iodoform  and  hydronaphthol  made  into  a  paste  with  pure 
oil  of  cloves  should  be  made,  when  the  cavity  can  safely  be  filled  with 
cement,  gutta-percha  or  amalgam,  as  seems  best  suited. 

Unless  positive  Infective  Inflammation  has  begun  such  cases  will 
usually  get  well  and  remain  so.  If,  however.  Infective  Inflammation  has 
begun,  which  can  usually  be  determined  by  the  history  of  the  case  and 
the  presence  of  an  exposure,  then  the  procedure  must  be  different. 

The  destruction  of  the  pulp  In  temporary  teeth  should  not  be  at- 
tempted with  the  use  of  arsenic;  the  chances  of  it  passing  through  the 


224 

wide  open  root  and  affecting  the  underlying  tissues  is  very  great,  as  well 
as  the  danger  to  the  surrounding  parts. 

Many  operators  suggest  the  use  of  corrosive  agents  such  as  zinc, 
chloride,  silver  nitrate  or  carbolic  acid,  which  will  often  work  well;  but 
I  find  the  ordinary  anodyne  treatment,  with  the  use  of  clove  oil  and  the 
like,  to  serve  fully  as  well,  which  will  keep  the  tooth  quiet  until  death  of 
the  pulp  results,  when  it  can  be  cared  for.  It  should  be  said,  however, 
that  exposed  pulps  of  deciduous  teeth  take  more  kindly  to  capping  than 
•do  the  pulps  of  permanent  ones. 

Putre$ccnt  0a$c$. 

In  the  management  of  putrescent  and  abscessed  cases  the  same  gen- 
eral principles  obtain  as  in  permanent  teeth  with  this  exception,  that  cor- 
rosive agents  are  never  needed. 

The  important  points  are  to  mechanically  clean  the  canals,  and  force 
^ome  oil  of  cloves  through  the  fistulous  opening  if  there  be  one,  and  if 
not  then  the  clove  oil  should  be  sealed  in  the  canal,  and  in  each  case  the 
clove  dressing  is  allowed  to  remain  a  week,  when  in  the  great  majority 
•of  cases  the  root  filling  may  be  proceeded  with. 

Koot  Tilling. 

As  a  root  filling  in  these  cases  I  have  had  excellent  results  from  the 
use  of  gutta-percha,  in  which  I  have  incorporated  a  little  iodoform  and 
hydronaphthol  dissolved  in  eucalyptol.  I  use  it  quite  thick  and  fill  the 
chamber  proper  with  gutta-percha.  The  tooth  cavity  may  be  filled  with 
any  material  suitable  to  the  case. 

$en$itife  Dentine. 

As  a  means  of  doing  away  with  the  sensitiveness  and  at  the  same 

time  stopping  the  progress  of  caries  in  shallow  cavities,  silver  nitrate 

is  very  efficacious. 

eieaning  teetl). 

It  is  important  to  keep  children's  teeth  clean,  and  as  often  as  tartar 
•or  green  stains  appear  they  should  be  removed.  The  removal  of  calculus 
and  polishing  the  teeth  is  a  very  simple  matter  for  children. 

A  little  hydrogen  dioxid  added  to  pumice  stone  will  aid  in  removing 
green  stains.  As  a  general  rule  it  is  never  advisable  to  keep  children  in 
the  dental  chair  longer  than  a  half  hour,  nor  is  it  advisable  to  adopt 
heroic  painful  measures  when  it  can  possibly  be  avoided  even  by  a  long 
way  around. 

By  diverting  the  attention  of  a  child  we  can  often  do  quite  painful 
things  and  have  them  bear  it  nicely ;  by  this  I  do  not  mean  that  it  is  ever 
permissible  to  deceive  a  child.  Once  deceive  a  child  he  will  always 
remember  it  and  will  never  trust  you  or  any  other  dentist  again.    By  put- 


225 

ting  into  child  phrases  the  condition  present,  and  what  you  are  trying  to 
do  for  his  rehef  and  future  comfort,  and  telhng  him  some  good  stories  of 
bravery  and  heroic  deeds,  and  incidentally  getting  him  interested  in  your 
imaginary  rabbits,  chickens,  etc.,  you  will  accomplish  what  you  desire  and 
he  will  bless  you  always. 

management  of  Permanent  Ceetb  Durins  Cbildbood. 

Very  little  needs  to  be  said  on  this  subject,  because  the  various  patho- 
logical conditions  have  already  been  presented  either  in  this  chapter  or  in 
the  preceding  ones.  Happily  the  diseases  of  the  gums  and  peridental 
membrane  are  rare  at  this  period.  I  only  wish  to  state  that  the  most 
critical  time  for  the  permanent  teeth  is  between  the  ages  of  six  and  four- 
teen, during  the  early  period  of  which  many  first  molars  are  lost.  Parents 
as  a  rule  regard  this  as  a  temporary  tooth,  and  before  the  dentist  has  an 
opportunity  to  correct  their  mistake  many  teeth  are  hopelessly  ruined. 

In  the  chapter  on  capping  pulps  reference  was  made  to  the  desir- 
ability of  keeping  pulps  alive  until  the  roots  are  fully  developed.  When 
the  pulp  is  gone  all  further  development  of  dentine  ceases,  and  teeth 
whose  roots  are  only  partially  formed  cannot  be  expected  to  do  a  lifetime 
service,  therefore  every  effort  should  be  made  to  preserve  the  pulp,  and 
when  pulps  are  lost  before  the  roots  are  nearly  completed  it  is  better  to 
extract  early,  especially  in  six  year  molars,  with  the  hope  that  the  space 
will  be  occupied  by  the  second  molar  by  and  by. 

manasement  of  Sensitive  €a$($. 

While  the  usual  obtundant  remedies  act  well  with  children,  it  must 
be  borne  in  mind  that  teeth  are  more  sensitive  during  this  period  than 
later  in  life.  Sensitive  to  malleting  in  fillings  and  also  to  excavating 
dentine,  and  that  growing,  maturing  children  cannot  bear  pain  as  well 
as  older  people,  and  yet  if  you  have  their  confidence  it  is  surprising  what 
they  will  endure. 

This  is  a  period  when  it  is  difficult  to  get  children  to  take  that  interest 
in  the  care  of  their  teeth  that  they  should,  and  consequently  good  mouth 
hygiene  is  often  lacking,  and  as  a  result  decay  is  more  prevalent. 

It  is  often  wisest  for  all  these  reasons  not  to  attempt  permanent 
gold  fillings,  but  rather  to  carry  the  teeth  along  in  comfort  with 
the  use  of  the  plastics  until  the  time  comes  when  all  these  conditions 
change  and  permanent  results  can  be  hoped  for. 


.  CHAPTER  XXII. 

facial  neuraldia. 

Etiology,     Neuralgic   Pains    of   Dental   Origin.      Causes.      Symptoms.      Diagnosis. 

Treatment.      Resection. 


The  term  neuralgia  is  derived  from  the  Greek,  and  signifies  nerve 
pain,  and  may  be  defined  as  "a  painful  afifection  of  the  nerves,  due  either 
to  functional  disturbance  of  their  central  or  peripheral  extremities  or  to 
neuritis  in  their  course." — Osier. 

Facial  neuralgia  is  a  term  used  to  designate  neuralgic  pains  in  the 
region  supplied  by  the  fifth  cranial  nerve,  sometimes  called  trifacial  and 
trigeminal  neuralgia. 

etioiosy. 

Individuals  who  suffer  from  any  chronic  nervous  disorder  are  most 
liable  to  this  affection.  \\^omen  more  liable  than  men,  and  syphilitic, 
gouty,  diabetic  or  anemic  persons  are  most  liable.  In  malarial  districts 
the  disease  is  very  prevalent.  Any  irritation,  especially  if  long  continued, 
to  any  sensory  nerve  filament  may  be  reflected  in  other  sensory  nerves, 
and  if  long  enough  continued  may  result  in  permanent  neuritis. 

The  trifacial  nerve  arises  by  two  roots,  a  small  motor  root  and  a  large 
sensory  root,  upon  which  is  situated  the  gasserion  ganglion.  Passing 
out  from  the  ganglion  are  three  main  branches.  First,  the  ophthalmic, 
which  with  its  branches  supplies  the  eye  muscles,  lachrymal  gland,  frontal 
muscles,  eyelids,  the  nose ;  second,  the  superior  maxillary,  which  with  its 
branches  supplies  the  upper  jaw,  the  teeth,  the  orbit,  the  cheek;  third,  in- 
ferior maxillary,  which  through  its  terminal  branches  supplies  the  lower 
jaw,  the  teeth  and  some  of  its  branching  filaments  pass  to  the  ear  and 
temporal  region. 

It  readily  can  be  seen,  therefore,  that  any  irritation  to  one  of  these 
branching  filaments  may  be  reflected  in  any  branch  of  all  three  main  divi- 
sions, and  there  is  possibility  of  certain  pains  being  transferred  to  another 
center  in  the  brain  through  the  anastomosing  branches  of  other  trunk 
nerves. 

neuralgic  Pains  of  Dentai  Origin. 

The  dentist  is  mostly  interested  in  pains  arising  from  the  dental 
organs  or  reflected  to  them.  Sometimes  these  reflexes  may  be  either  or 
both  motor  and  sensory,  manifesting  itself  in  pain  and  motor  twitching 
and  spasms. 


227 


Causes. 

Facial  neuralgia  may  develop  from  a  variety  of  causes,  both  local 
and  constitutional,  as  previously  stated.  When  local  the  cause  frequently 
lies  within  the  tooth  pulp  or  peridental  membrane.  Hyperemia  of  the  pulp 
IS  sometimes  the  exciting  cause.  Pulp  nodules  impinging  on  the  nerve 
filaments,  all  of  which  is  contained  with  the  walls  of  the  pulp  canals, 
may  be  an  exciting  cause;  a  case  in  point  has  been  cited  in  Chapter  IV. 
Uncovered  sensitive  dentine  may  transmit  neuralgic  pains. 

Hypercementosis  is  sometimes  considered  a  cause;  septic  diseases 
of  the  pulp  have  also  been  considered  a  cause. 

Impacted  teeth,  particularly  lower  third  molars,  spicula  of  bone  left 
after  extraction,  may  impinge  on  the  nerve.  Ill-fitting  lower  dentures 
may  press  on  the  mental  foramen,  tumors  in  the  bone,  aneurysms,  tumors 
of  the  nerves  are  frequent  local  causes. 

Other  causes  which  lie  outside  of  the  strictly  dental  organs  are 
catarrhal  conditions  of  the  frontal  or  of  the  maxillary  sinuses,  inflam- 
matory conditions  about  the  eye  and  ear,  and  most  important  of  all,  in- 
flammation of  the  nerves  of  the  region  affected,  impingement  of  nerves 
in  cicatrics  about  the  jaws,  following  surgical  operations. 

All  of  these  act  more  or  less  severe,  according  to  this  idiosyncrasy  of 
the  patient  and  the  peculiar  constitutional  conditions  present.  After  all  has 
been  said  regarding  these  causes  it  must  be  stated  that  the  more  severe 
forms  of  facial  neuralgia  do  not  come  from  these  sources,  but  in  all 
probability  arise  from  the  nerve  trunk  itself  or  in  the  brain  cells. 

That  most  horrible  of  all  forms,  known  as  tic-douloureux,  cannot  be 
said  to  be  caused  by  any  condition  associated  with  the  teeth,  unless  it 
be  as  a  mere  starting  point,  from  which  it  rapidly  passes  into  serious  trunk 
nerve  disturbances,  if,  indeed,  the  brain  cells  are  not  the  source.  (Manv 
think  anemia  of  the  nerve  trunk  is  the  cause.) 

About  this  particular  neuralgia  we  know  very  little  except  its  mani- 
festations. It  produces  the  most  excruciating  pain;  its  attacks  are 
paroxysmal,  occurring  with  ever-increasing  frequency  until  life  becomes 
absolutely  unendurable.  The  sight  of  the  suffering  of  even  one 
of  these  unfortunate  victims  will  make  a  lasting  impression  on 
the   observer. 

When  due  to  other  dental  causes  than  these  there  is  never  any  con- 
stancy regarding  the  location  of  the  pain;  sometimes  it  will  appear  in 
one  spot  and  sometimes  in  another;  tenderness  of  the  eyeball,  the  tem- 
poral and  anterior  auricular  region,  will  usually  indicate  the  trouble  to 
be  in  the  same  part  of  the  inferior  maxillary  branch. 

Sometimes  pains  deflected  to  the  ear,  to  the  mastoid  cells,  in  the 
infra-orbital  or  mental  foramen  region  (Dr.  Brophy  has  recited  some  inter- 


228 

esting  cases  of  this  character)   have  their  origin  in  the  lower  teeth  or 
jaw. 

It  is  very  rare  to  find  neuralgia  of  dental  origin  affecting  more  than 
one  of  the  trifacial  branches  at  a  time ;  the  one  most  commonly  affected 
when  of  dental  origin  is  the  inferior  maxillary ;  when  the  upper  teeth  are 
responsible  the  pain  may  be  deflected  to  the  lip,  nose  or  the  cheek. 

Symptoms. 

There  are  very  few  dependable  symptoms,  although  certain  symptoms 
may  serve  as  guide  posts  to  direct  the  practitioner  to  the  source.  Before 
the  onset  of  the  pain  there  may  be  a  peculiar  tingling  sensation  in  the 
part.  The  pain  is  not  constant  like  from  a  forming  abscess,  but  parox- 
ysmal darting  pains,  twitching  of  the  muscles  of  the  part  is  usual. 

The  spasms  come  and  go  sometimes  at  regular  intervals,  and  if  it 
be  a  true  neuralgia  of  trophic  affection  the  pain  will  become  severe,  and 
even  the  skin  may  become  so  sensitive  that  the  slightest  touch  will  cause 
the  sufferer  to  cry  out  with  the  pain. 

If  the  pain  be  reflex  and  due  to  dental  origin  usually  there  is  some 
discomfort  about  the  mouth,  or  a  careful  examination  as  to  caries,  in- 
flamed pulps,  pericementitic  erosions  and  the  like  will  reveal  the  cause. 
As  stated  before,  when  the  teeth  themselves  are  responsible,  it  usually 
can  be  easily  found  either  hot  or  cold  sudden  changes,  recumbent  posi- 
tion, tenderness  to  percussion  or  some  recognizable  disturbance  can  be 
seen. 

When  due  to  other  than  these  peripheral  causes  the  nerves  will  be 
tender  to  pressure  at  the  points  where  they  emerge  from  the  bone. 

Diagnosis. 

The  first  essential  in  making  a  diagnosis  of  this  trouble  is  to  get  a 
complete  history  of  the  case,  even  to  the  minutest  detail ;  the  patient  may 
be  able  to  give  you  a  clue  to  the  real  trouble.  The  actual  diagnosis 
must  be  made  by  exclusion ;  examine  each  tooth  on  the  affected  side  for 
every  known  lesion,  and,  if  none  is  found,  the  X-ray  may  be  helpful  in 
locating  hypercementosis,  pulp,  nodules  or  impacted  teeth,  as  well  as 
tumors. 

Next  the  region  of  the  affected  nerves  should  be  examined  for  tender 
spots,  which  in  tic-douloureux  are  located  at  the  supra-orbital  foramen, 
the  upper  eyelid,  the  cartilage  of  the  nose,  the  parital  eminence,  when  the 
ophthalmic  branch  is  affected.  The  infra-orbital  foramen,  malor  bone, 
upper  lip,  palate  or  other  places  in  the  upper  jaw  will  be  tender,  when 
the  superior  maxillary  is  affected,  or  the  tender  spots  may  be  in  front  of 
the  ear,  over  the  inferior  dental  foramen  or  over  the  mental  foramen  when 
the  inferior  maxillarv  branch  is  affected. 


229 

treatment. 

If  any  dental  lesion  exist  it  should  be  put  in  order,  and  thrice  happy 
A-ou  should  be  if  in  doing  so  the  source  of  the  trouble  has  been  found.  It 
must  be  remembered  that  these  pains  sometimes  continue  for  a  few  days 
after  the  exciting  cause  has  been  removed,  but  will  gradually  grow  less 
and  less. 

^lany  therapeutic  agents  have  been  suggested  as  available  in  the 
treatment  of  facial  neuralgia,  among  which  are  the  following : 

Phenacetine  acetanilid  in  doses  from  five  to  ten  grains  in  neuralgic 
pains  about  the  face  due  to  exposure  to  cold  and  dental  irritation.  Aco- 
nite tincture  in  five  drop  doses  every  twenty  minutes  will  usually  help  the 
acute  forms;  it  is  administered  until  numbness  of  the  lips  appear;  it  is 
also  u.^ed  as  a  lotion  painted  liberally  over  the  affected  parts. 

Arsenic  in  the  form  of  Fowler's  solution  is  especially  recommended 
for  neuralgias  of  malarial  origin.  It  is  best  to  begin  with  about  ten 
minims  and  gradually  decrease  until  one  minim  is  given,  then  gradually 
increase  again. 

Butyl-chloral  hydrate  is  strongly  recommended  in  doses  of  about  five 
grains.  I\Iany  seem  to  rely  on  this  drug.  A  mixture  of  butyl-chloral 
hydrate  and  tincture  of  camphor  may  be  locally  applied. 

Belladonna  is  very  useful  if  violent  spasms  are  present. 

Gelsemium  in  the  form  of  the  tincture  and  also  the  sulphate  gelsemi- 
nine  has  been  found  by  the  author  to  be  very  efficacious  when  the  neuralgia 
is  of  dental  origin. 

Colcliicum  is  a  valuable  remedy  when  the  neuralgia  is  of  gouty  origin, 
best  given  in  form  of  the  wine  of  colchicum  root,  dose  5-20  minims. 

Cannabis  Indica  has  been  praised  as  a  remedy  by  manv  writers,  but 
the  author  has  had  very  negative  results. 

The  opiates  can  never  be  considered  as  curative,  but  thev  are  often 
our  only  means  of  controlling  the  severe  pain.  ^lany  recommend  inject- 
ing morphine  directly  into  the  afifected  region. 

Cod  liver  oil  and  phosphorus  has  proven  very  efficacious  in  four  cases 
treated  by  the  author. 

Iroji  and  qiii)ii}ic  are  given  often  with  helpful  results  when  neural- 
gia is  due  to  anaemia  and  malaria. 

Local  application  of  freezing  mixtures  such  as  methyl-chloride  sprayed 
over  the  affected  region  has  been  helpful  in  some  cases. 

Electricity  is  considered  by  many  very  helpful.  It  must  be  carefully 
applied,  using  the  positive  electrode  over  the  seat  of  the  trouble.  The 
current  should  be  increased  gradually  and  continued  for  twenty  minutes 
at  a  time  and  repeated  daily. 


230 

Castor  oil  treatment  has  been  highly  praised  by  many  neurologists. 
The  plan  seems  to  be  to  give  as  much  castor  oil  as  possible  without 
purgative  effect.  Dr.  Patrick  suggests  that  it  is  best  given  at  bedtime. 
The  first  night  a  large  dose  is  given  which  will  purge  considerably ;  the 
next  night  the  same  dose  will  purge  less.  This  plan  is  followed  for  three 
or  four  days,  when  an  additional  dose  may  be  given  in  the  morning  with- 
out purgative  effect,  and  thus  gradually  the  patient  can  take  from  two  to 
four  ounces  in  twenty-four  hours  without  active  purgation  and  at  this 
point  the  real  benefit  begins. 

The  same  author  says  that  he  has  found  this  treatment  beneficial  in 
40  per  cent  of  the  cases  and  curative  in  a  somewhat  smaller  percentage. 

In  the  treatment  of  these  cases  it  is  wise  to  try  all  of  these  means  of 
relief  before  attempting  the  surgical  methods,  for  the  reason  that  even 
surgery  fails  to  permanently  cure  many  of  these  severe  cases. 

I  have  known  of  several  cases  where  extraction  of  one  tooth  after 
another  until  all  on  the  affected  side  were  removed  with  only  temporary 
benefit,  and  others  where  removal  of  the  nerves  in  both  jaws  brought 
relief  only  for  a  few  weeks.  A  great  variety  of  surgical  operations  have 
been  tried  in  times  past  for  the  relief  of  this  trouble,  all  but  four  of  which 
have  been  discarded. 

The  removal  of  the  Gasserion  ganglion  promises  the  most  perma- 
nent results,  but  even  this  has  failed,  and  lately  a  suggestion  has  come 
from  Abbe  to  sever  the  maxillary  branches  from  the  ganglion  and  place 
a  piece  of  gutta-percha  between  the  severed  ends,  thus  preventing  any 
future  reunion.  This  operation  is  fraught  with  grave  dangers  to  life  and 
does  not  promise  a  permanent  cure  in  all  cases. 

A  German  scientist  has  recently  suggested  injecting  into  the  ganglion 
a  one-half  per  cent  solution  of  osmic  acid.  It  seems  to  have  proved 
successful  in  a  few  cases. 

Resection. 

llesection,  an  operation  by  which  a  portion  of  the  affected  nerve  is 
removed.  If  the  affected  portion  is  removed  before  the  entire  trunk  is 
involved  success  will  follow,  and  in  any  event  the  patient  will  be  free 
from  pain  for  a  period  from  two  to  six  years. 

This  operation  is  simple  compared  with  that  of  removing  the  gan- 
glion, and  if  skillfully  done  is  not  dangerous.  ]\Iost  surgeons  recommend 
that  this  operation  be  tried  first,  and  if  necessary  the  ganglion  removed 
later. 

Subcutaneous  division,  an  operation  by  which  the  nerve  trunk  is  di- 
vided, is  successful  for  a  short  time;  but  my  experience  is  that  the  pain 
returns  with  greater  force  and  persistency. 


22,1 

Evulsion,  an  operation  by  which  a  portion  of  the  nerve  is  torn  out, 
is  highly  recommended  by  some  surgeons,  and  by  this  method  it  is  pos- 
sible to  tear  out  the  nerve  for  a  considerable  distance,  and  thus  bring 
freedom  from  pain  for  a  considerable  time. 

A  description  of  the  technique  of  these  operations  does  not  come 
within  the  province  of  a  work  on  therapeutics.  The  reader  is  referred  to 
modern  text  books  on  surgical  procedure. 


CHAPTER  XXIII. 

SDock* 

Etiology.     Symptoms.      Causes.     Treatment. 


Shock  is  a  depression  of  the  vital  powers  caused  by  injuries  or  from 
some  great  mental  disturbance.  It  is  manifest  by  a  sudden  check  in  the 
circulation  brought  about  through  the  cerebro-spinal  centers. 

etiology. 

The  condition  follows  accidents  often  in  railway  trains,  or  it  may 
follow  a  profound  mental  impression  or  severe  prolonged  mental  strain. 
It  is  not  necessary  that  there  be  some  physical  lesion  in  order  to  produce 
shock  from  accidents,  indeed,  some  of  the  severe  forms  appear  when  no 
physical  signs  can  be  found. 

Shock  from  dental  and  surgical  operations  sometimes  result  when 
there  is  little  or  no  loss  of  blood  and  most  frequently  from  prolonged 
sittings  in  the  dental  chair ;  not  always  on  account  of  the  pain,  but  most 
frequently  as  a  result  of  long  mental  strain  from  dread  or  fear. 

Shock  is  not  to  be  confounded  with  simple  fainting,  in  which  there 
is  also  a  cessation  of  vital  functioning.  Shock  may  or  may  not  appear 
for  some  time  after  accidents  or  operations.  The  usual  history  when 
caused  by  dental  operations  is,  first,  a  feeling  of  over-excitement,  which 
gradually  passes  into  prostration,  which  may  last  for  several  days ;  and  a 
few  cases  are  reported  where  patients  failed  to  rally  and  death  resulted. 

Symptoms. 

The  symptoms  of  shock  usually  begin  by  a  tired  feeling  and  appear- 
ance of  prostration,  and  if  profound  the  patient  passes  into  a  state  of 
coma,  where  consciousness  can  scarcely  be  aroused,  pallor  of  the  face  and 
the  whole  body  surface,  which  is  especially  seen  in  the  lips.  The  body 
is  cold  and  covered  with  sweat,  the  eyelids  droop,  the  features  look 
pinched  or  the  eyes  in  severe  cases  remain  wide  open  and  staring  and  have 
a  weird  and  uncanny  sunken  look.  The  pulse  is  almost  imperceptible,  very 
weak  and  thready.  The  thermometer  will  show  a  temperature  of  96°  or 
97°,  respiration  is  short  and  feeble,  or  may  be  panting. 

In  these  cases  there  is  usually  no  great  loss  of  sensibilities.  Some- 
times there  will  appear  marked  hysteria. 

pauses. 

Whatever  the  source  of  shock  may  be,  it  produces  heart  disturbance 
through  the  vaso  motor  system ;  there  is  a  partial  paralysis  of  this  system, 
with  some  real  cell  injury  which  at  present  is  not  thoroughly  understood. 


233 

Many  regard  shock  as  a  temporary  paresis  of  the  muscles  of  the  heart, 
but  there  evidently  must  be  something  more,  and  is  probably  explained  by 
the  theory  of  molecular  nerve  cell  disturbance.  Prognosis  of  shock  is 
always  uncertain.  Of  course  the  severity  of  the  form  will  have  much  to 
do  with  the  outcome. 

treatment. 

The  treatment  must  always  be  based  on  the  severity  of  the  various 
symptoms.  The  recumbent  position  is  essential.  As  soon  as  possible 
warm  stimulating  drinks  should  be  given ;  whiskey  or  brandy  are  com- 
mon remedies  which  are  valuable.  Volatile  heart  and  respiratory  stimu- 
lants, such  as  amyl  nitrate  and  ammonia,  should  be  held  before  the  face 
to  tide  over  the  temporary  vital  depression. 

The  slapping  of  the  face  with  a  cold  wet  towel  and  the  chafing  of  the 
extremities  are  helpful  especially  in  the  cases  of  syncope  or  fainting. 
Then  artificial  respiration  should  be  undertaken  and  kept  up  as  long  as  it 
is  helpful. 

Hypodermic  injections  of  atropine  to  maintain  the  respiration  and 
nitro-glycerine,  one  two-hundredth  of  a  grain.  Digitalis  and  strychnine, 
one-twentieth  of  a  grain,  are  the  remedies  to  support  the  circulation. 

When  hysterical  excitement  prevails,  morphine  one-eighth  to  one- 
fourth  of  a  grain  should  be  given.  When  the  patient  can  readily  swallow, 
the  aromatic  spirits  of  ammonia  is  a  valuable  remedy,  as  well  as  valerian. 

In  concluding  this  article  I  wish  to  call  attention  to  the  danger  of 
shock  from  severe  prolonged  dental  operations.  The  symptoms  may  not 
appear  at  the  time,  but  may  develop  several  hours  or  days  after  the  sit- 
ting. Long  sittings  should  be  avoided,  especially  if  patients  are  nervous 
or  excitable. 

It  is  better  to  make  two  or  more  short  sittings,  or  if  necessary  make 
only  temporary  operations  rather  than  run  the  risk  of  inducing  disturb- 
ances which  are  fraught  with  such  grave  dangers. 

The  medicine  case  should  always  be  supplied  with  the  usual  remedies 
indicated  in  these  cases,  for  oftentimes  they  will  be  called  for  on  a 
moment's  notice. 


INDEX 


Active  Hyperemia,  Causes  of,  39. 

Agents,  154. 

An  After  Word,  214. 

Alveolar  Abscess,  110. 

Chronic,   118. 

Replantation,   as  a   Cure  for,   191. 
Aneurysm,   122, 
Aphthous  Stomatitis,   196. 
Apical   Pericementitis,   106. 

Chronic.  109. 

Bacteria   of   Pus,   the,   95. 

Bacteriology  of  Dental  Caries,   10. 

Blind  Abscess,  123. 

Blood  Supply  Nerves,   106. 

Blood  Vessels,   17. 

Broach   Sterilization,    135. 

Calcic   Inflammation,   160. 

Calcific  Degeneration  of  the  Pulp,  36. 

Caries,   Dental,  6. 

Carrying  Infection,  134. 

Cases,  109. 

Cases  of  Open  Cavities,  93. 

Case's    of   Putrefaction   Under    Fillings, 

93. 
Causation,  34. 


Causes,  57,  106,  111,  204,  219,  227,  232. 

of  Active  Hyperemia,  39. 

Hyperecementosis,    186. 

Hyperemia  of  the  Dental  Pulp,  40. 

of  Inflammation,  47. 

Passive  Hyperemia,  39. 

Tooth  Discoloration,   151. 
Cells,  104. 

Other,    17. 
Changes    Continued,   Destructive,   45. 

in  the  Pulp ;  Destructive,  39. 
Children's    Teeth,    Management    of   the 

Diseases  of,  220. 
Chlorin  Method,   157. 
Chronic  Alveolar  Abscess,  118. 

Apical   Pericementitis,   109. 
Cleaning  Teeth,  224. 
Cleansing  and   Filling   Pulp   Chambers, 

71. 
Congenital  Syphilis,  214. 
Conheim's  Theory,  49. 
Constructive   Diseases   of  the   Pulp,   31. 
Curative  Method,   11. 

Degeneration  of  the  Pulp,  Calcific,  36. 
Dental  Caries,  6. 

Bacteriology  of,  10. 

Pulp,  the,  13. 


Dentine,    Hypersensitive,    19. 

Sensitive,  16,  224. 
Dentition,  220. 
Destructive   Changes    Continued,  45. 

in  the  Pulp,  39. 
Diagnosis,  174,  206,  228. 

Positive,  209. 
Direct  Oxygen  Method,  the,  155. 
Discolorations,   43. 

Discolored  Teeth,  Management  of,  151. 
Diseases  Affecting  the  Peridental  Mem- 
brane   About   the    Apices    of   the 
Roots  of  Teeth,  102. 
of  Children's  Teeth,  Management  of 

the,  220. 
of  Deciduous   Teeth  and   Soft  Tis- 
sues of  the  Mouth,  the,  223. 
of  the  Maxillary  Sinus,  216. 
of  the  Peridental  Membrane   Hav- 
ing Their   Beginning  at  the   Gin- 
givus,   158. 
of  the  Pulp,  223. 
Constructive,  31. 

of  the  Soft  Tissues   of  the  Mouth, 
196. 
Dry  Scaling  Papule,  the,  207. 


Eczema  of  the  Tongue,  202. 
Empyema,  216. 
Ethereal  Solution,  155. 
Etiology,  217,  226,  232. 

from  a  Therapeutic  Standpoint,  19. 

of   Phagedenic    Pericementitis,    172. 


Germicides,  133. 

Some  Dental  Uses,  137. 
General    Considerations,    151. 

Histological  Structure  of  the  Peridental 
Membrane,   102. 

Pli story,   6,   59. 

How   to    Cure   Hyperemia   and   Inflam- 
mation in  Tooth  Pulp,  56. 

Hypercementosis     and     Root     Resorp- 
tions,   183. 
Causes  of,  186. 

Hyperemia,  39. 

of  the  Dental  Pulp,  Causes  of,  40. 

Hypersensitive   Dentine,    19. 

Plypertrophy  of  the   Pulp,  55. 

Immunity  and  Susceptibility,  82. 
Infection,  133. 

Carrying,  134. 

Instruments  Sterilization  and  Germ- 
icides,  133. 
Inflammation,  45. 

as  a  Reparative  Process,  48. 

Calcic,  160. 

Causes  of,  47. 

of  the  Tooth   Pulp,    Symptoms   of, 
54. 

Treatment  of,  57. 

Symptoms  of  Local,  47". 

Treatment  of,  54. 
Instruments,  175. 

Instruments    Sterilization,    133,    136. 
Introductory,   6. 


Facial  Neuralgia,  226. 

Favorable  and  Unfavorable  Cases,  60. 

Fever,  89. 

Symptoms  of,  90. 
Filling  Pulp  Canals,  80. 

Chambers,   Cleansing  and,   71. 
Functions,  102. 

of  the  Pulp,  the,  16. 


Germicidal  Solution,   a,   135. 


Kinds  of  Pus,  88. 

Leukoplakia,  203. 

Local  Inflammation,   Symptoms  of,  47. 

Location,  205. 

Loose  Teeth,   Management  of,   179. 

Management  of  Discolored  Teeth,  151. 
Loose  Teeth,  179. 
Permanent    Teeth     During     Child- 
hood, 225. 


ni 


Management  of  Sensitive  Cases,  19,  225. 

Sensitive  Dentine.  25. 

the    Diseases    of    Children's    Teeth, 
220. 
Maxillary  Sinus,  Diseases  of  the,  216. 
Medication,   Systemic,   24. 
Mercurial   Stomatitis  (Ptyalism),  200. 
Method  of  Using,  155. 
Methods,  64. 

Curative,   11. 

of  Pulp  Capping,  61. 

of  Tooth  Bleaching,  153. 
Morbid  Anatomy,  183. 

Necrosis,  219. 

Nerve  Supply,  17. 

Neuralgia,  Facial,  226. 

Neuralgic  Pains  of  Dental  Origin,  226. 

Obtundants,  25. 
Open  Cavities,  Cases  of,  93. 
Oral    Manifestations    of    Syphilis,    Gen- 
eral  Considerations,   205. 
Other  Cells,  17. 


Painful   Process,  42. 
Passive  Hyperemia,   Causes  of,  39. 
Pathology,  186,  208,  222. 
Peridental  Membrane  About  the  Apices 
of  the  Roots   of  Teeth,   Diseases 
Afifecting  the.  102. 
Having     Their     Beginning    at    the 

gingivus.   Diseases  of  the,  158. 
Histological  Structures  of  the,  102. 
Permanent    Teeth     During    Childhood, 

Management   of,   225. 
Phagedenic   Pericementitis.    170. 
Etiology  of,  172. 
Treatment  of,  174. 
Plantation  of  Teeth,  Resection  of  Roots 

and,  189. 
Positive  Diagnosis,  209. 
Preparation   of   Cavity   to    Receive   Ar- 
senic,  68. 


Prognosis,  179. 
Pulp  Canals,  Filling,  80. 
Capping,   59. 
Methods  of,  61. 

Chamber,  the,  71. 

Devitalization,  63. 

Diseases  of  the,  223. 

Functions  of  the,  16. 
Pulpless  Teeth,   Treatment  of,   124. 
Pulp   Nodules,  34. 

Secondary  Dentine  and,   31. 

the  Dental,  13. 
Pus,  Kinds  of,  88. 

the  Bacteria  ot,  95. 
Putrefaction   Under   Fillings,    Cases   of, 

93. 
Putrescent  Cases,  224. 

Pulps,   91. 

Recent  Theories,  7. 

Removal  of  Salivary  Calculus,   162. 

Stains  from  the  Teeth,  165. 
Removing  Pulps,  77. 
Reparative  Process,  Inflammation  as  a, 

48. 
Replantation    as    a    Cure    for    Alveolar 

Abscess,  191. 
Resection,  230. 

of  Roots   and   Plantation   of  Teeth, 

189. 
Root  Filling,  224. 

Salivary   Calculus,    161. 

Removal  of,  162. 
Scalers,   163. 

Secondary  Dentine  and  Pulp   Nodules, 
81. 

Eruption,  210. 

Stages   of  Syphilis,  the,  210. 
Sensitive  Cases,  Management  of,  19,  225. 

Dentine,  16,  224. 

Management  of,  25. 
Sensitiveness,  Thermal,  28. 
Serumal  Calcic  Inflammation  and  Pha- 
gedenic     Pericementitis,      Treat- 
ment of,   174. 

Calculus,    165. 


IV 


Shock,  232. 

Sodium  Dioxid,   Na.  O2,  155. 
Soft  Tissues  of  the  Mouth,  Diseases  of, 
196. 

Source  of  Infection,  205. 

Special    Cases,    129. 

Stains  from  the  Teeth,  Removal  of,  165. 

Sterilization,   Broach,  135. 

Instrument,  136. 
Stomatitis,  196. 

Aphthous,  196. 

(Ptyalism),   Mercurial,   200. 

Ulcerative,   199. 
Structures,   102. 

Suppuration  of  the  Pulp,  91. 
Tooth  Pulp,  82. 

Susceptibility,    Immunity   and.    82. 

Symptomology,  43. 

Symptoms,  35,  106,  187,  200,  228,  232. 
and   Diagnosis,  217. 
Pathology,  114. 
of  Fever,  90. 
Inflammation   of  the   Tooth   Pulps, 

54. 
Local  Inflammation,  47. 


Syphilis,  Congenital,  214. 

General  Considerations;  Oral  Mani- 
festations of,  205.  ■  - 

Tertiary,  212. 
Systemic  Medication,  24. 

Teeth,   Cleaning,  224. 

Tertiary  Syphilis,   212. 

Therapeutics,  10. 

Thermal  Sensitiveness,  28. 

Tooth  Bleaching,  Methods  of,  153. 

Discoloration,  Causes  of,   151. 

Pulp,  Suppuration  of  the,  82. 
Treatment,  44,  94,  107,  109,  114,  162,  175, 
197,   200,   204,   212,    217,   219,   222, 
229,  233. 

of  Inflammation,  54. 

of  the  Tooth  Pulp,  57. 

Pulpless  Teeth,  124. 

Serumal    Calcic    Inflammation    and 
Phagedenic  Pericementitis,  174. 
Tumors,  219. 

Ulcerative   Stomatitis,   199. 
Ulcers,  218. 

Variations  of  the  Form  of  Pulp  Cham- 
bers,  77. 

Willard,  E.S.,   D.D.S.,  95. 


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